Guest Post: Libby Zion

Today’s guest post is by James Lawther.  James gets upset by operations that don’t work and apoplectic about poor customer service.  Visit his web site “The Squawk Point” to find out more about service improvement.

On 4th March 1984 Libby Zion (an 18 year old known to be using anti-depressants) was admitted into a hospital in New York with a high fever.

That night, Luise Weinstein, a medical intern 8 months out of medical school, was on call. He discussed her case over the phone with a senior doctor, and then prescribed two drugs, a pain killer and a sedative.

The next morning Libby was dead.

The subsequent inquest found that a reaction between the two medicines and her anti-depressants was the cause of Libby’s death.

Why was she prescribed those drugs by the medic? Didn’t he know what would happen?

It transpires that like all medical interns he had been working a long shift. He was over worked and sleep deprived and made the wrong decision.

How long do you work?

How long can you expect somebody to work? In the UK and US there are laws that prevent lorry drivers from working more than 11 hours without a 10 hour break.

11 hours is also the time it takes to fly from London to Los Angeles. Would you get on a plane flying the return leg if you knew that the pilot had just flown the outbound trip?

That shift, Luise Weinstein had worked 36 hours.

A change in the law

Libby Zion’s father happened to be a journalist and he did what all good Journalists do. He created a story, a mass of publicity. In response the governor of New York set up a committee to look into the case and in 1989 the law changed in New York State forbidding Medical residents to work:

• More than 24 consecutive hours
• More than an 80 hour working week

Remember that plane trip?

Ten years later the New York State Department of Health conducted surprise inspections at a number of hospitals. They found that over half of surgical residents work in excess of 95 hours a week .

Why do the hospitals flout the law? Simply because it would cost them a lot of money to obey it.

The problem with focusing on cost

Lean thinkers talk about purpose, they say you should always focus on purpose first and foremost. If you do that efficiencies and cost savings will come as a by-product.

Hippocrates is often quoted as saying “first do no harm”.

Perhaps that would be a good purpose for the hospitals to focus on.

James writes about process improvement at www.squawkpoint.com

One Reason Our Healthcare Costs Are Increasing

One industry that lean is starting to penetrate is the health care industry.  After experiencing a story of a relative last week, it made me sick to hear how insurance companies don’t help the situation of increasing cost.

The person is on a medication that is extremely hard to get approved for by the insurance companies.  Approval from the insurance companies is a must because most people can’t afford the medication without it.

A few years back the person was approved for the medication after a 4 month process.  When they started the medication the expectation was they would be on it for at least 15 years or so.  It basically is part of their life at that point.

Fast forward to present day.  The person has responded incredibly well to the medication.  In fact, they responded so well, there is thought that the person may not have to take it anymore, but the doctors can’t take the patient off of the medication because if they do and the patient does need the medication the doctors will not be able to get the patient approved a second time.  At least it has never happened yet.

Because of the pain and inflexibility of the insurance companies, the patient and the doctors are in a tight spot.  Do they keep the patient on the medication even though they may not need it or do they go a few months without the medication but still filling the prescriptions and holding on to the medication so the patient doesn’t loss eligibility?

Either way, it is money out of the patient’s pocket that could be saved.  Plus, additional cost to the insurance company of a VERY expensive medication.  In either of these cases, more costs will be added causing insurance premiums, medications, the whole health care system to increase.

This just isn’t right.  The system has made it nearly impossible to do the right thing and extremely easy to do the wrong thing.  As a country, we have a long way to go to fix some deep rooted issues with our health care system, which I believe is still one of the best in the world.

Bad Processes Beat Good People

About 3 years ago, I had to take my wife to the ER when we were living in Texas.  That night really tested me on living up to the quote, “Good processes beat good people.”  This means we should always look at the process.  Don’t blame the people, blame the process and fix it.  Well, on this night, in extreme circumstances, I failed to live up to it.  Even getting upset with a nurse at one point.  Below is a recount of the night that I posted on the Lean Blog the week after it happened.

Can you see all the improvement opportunities that lean could help with in this hospital?

Saturday night, I had to take my wife to one of the local ERs. We got there at 9:40pm. When we got there, I filled out paperwork to register her with all the basic information (name, symptoms, SSN, address, etc…….). Then we had to sit there and wait……..and wait…….and wait. This was especially frustrating since wife was curled up in the fetal position in extreme agony and no one evened seemed to care.

The maddening part was there was no privacy (except chest pain). Everyone else in the ER had minor things (sprained ankle, minor headache, etc……..). After we checked in a mother with a baby that could not have been older than 1 came in. The baby was green! It freaked me out. It was the one person I thought should get bumped in front of us, but they didn’t. They waited in the FIFO line too.

After 30+ minutes we got called into the triage room where half the questions that got asked were repeat questions that I filled out earlier. I found this frustrating since the data from our registration sheet was put into the computer and that is how triage got our name and called us in. Where did the rest of our data go? Why ask again? The triage nurse said this was part of registration.

Then we went back out into the waiting room and waited for another hour before they called us back. As they were taking us back they stopped me and said that I had to register to go back with my wife. I had to register at the same desk as the first registration an hour and a half earlier. So, my wife is in agony and can barely walk and I have to stay up front to have my ID scanned and a sticker badge given to me. Then I get let in and I have to search for her room. I finally find her and we wait for a third person to come in and ask the same registration questions again. She is even wearing a badge that says “Registration” on it. My wife asks why this wasn’t done in the waiting room where we have been for that last 1.5 – 2.0 hrs. The lady replies that “this is just the process.” We could’ve had all the registering done in the waiting room up front. This seems to be a little more batch (“batching all the paperwork up front”), but I would argue two points: 1. there isn’t as much batching as one might think because we are getting all the same questions over and over with a couple of new ones, and 2. this would be more customer focused because my wife is in pain and we wouldn’t be separated plus she wouldn’t be getting upset about answering all the same questions over and over again.

At this point, my wife looks up an me and says, “This isn’t very lean is it?” I was glad to see her smile through the pain.

We wait for a long time and finally see a doctor who orders a CT scan, so we wait for the scanner to be setup and then we wait for the results and then we wait for the doctor, etc………….. During all this waiting I speak with some of the nurses. At this point it is about 1 or 1:30am. The nurse tells me this is a real slow night. Usually the halls are lined up with patients. I notice that they can’t find their electronic thermometer and go borrow one from another area, the supply area is labeled but is very messy and can’t tell how much is supposed to be there. The nurses can’t find things and quite a few times are just sitting around talking about their lives outside of work. They spent a lot of time doing this. Not because they don’t care but because they are waiting on doctors and information and whatever they need to treat the patients.

The most disheartening thing I heard all night was about a computer. I heard that they had test results back on the baby that was green (and I literally mean green) but nobody has been able to view them for an hour. They were having problems getting the computer to work so they called IT. There was no manual override or way to get results so the baby couldn’t be treated until they got the computer working. WHAT!!!!!!!!!?????????? I couldn’t believe what I was hearing. I don’t know what happened to the baby and the test results but I hope everything turned out alright.

At 2:30am, we finally left the ER with pain medicine in hand nearly 5 hrs after walking in the door. I figure only about an hour was value added. This is being generous too because it includes the walk time to the CT scan and the 20 minutes we had to wait after receiving the pain meds before we could leave.

I was thinking about lean stuff all night and trying not to blame the people but at times I would even find myself getting upset with the people “just sitting there” and not helping. My emotions would just take over as I watched my wife in pain.

I have always believed that lean is for everyone and every place because it is the mindset. Saturday night was just one of those “hit home” experiences that brought it to light.

What do you see that the hospital could have done from a lean perspective?  Do you have a story to share?

It was a very enlightening experience that has still stuck with me today.  I try my hardest to always remember that no matter how positive the intent of the person is, if the process is designed poorly, eventually the process will beat the people.

Lack of Handoff Integrity and Empowerment

A couple of weeks ago, my wife was dealing with a mess between our health insurance provider and our flex plan provider.  This is our first year of using a Flex Plan that pulls money directly from my paycheck (before taxes) into an account to be used on medical visits, prescriptions, etc…  Everyone mentioned how wonderful this is.  It is kind of like level loading the payment for doctor visits and prescriptions we would need during the year.  This is suppose to be a seamless process for us.  The insurance company is suppose to automatically send processed claims through to the flex account provider.  At that time, the flex account provider is suppose directly deposit the money into our checking account for us to pay the bills.

If you noticed, I used the word ‘suppose’ a lot above.  There is a good reason for that.  The process is not working like that at all.

After a few months, my wife had noticed that we hadn’t received our reimbursement from our flex plan for several doctor visits.  She keeps meticulous records, so she knew exactly what the amounts were, what doctor, and for what.  My wife called our flex plan provider.  It didn’t take long before the flex plan provider pointed the finger at the insurance provider.  I think it was put this way, “We can’t reimburse you if we haven’t received any notice so it is their fault.”

That led to a call to our insurance provider.  My wife spent almost an hour on the phone with them.  The insurance provider said they sent it.  Their system showed it was sent on a specific date.  My wife asked how often do they send claims to the flex plan provider and do they get a confirmation of receipt back?  It was explained to her that all claims are sent out electronically to the flex plan provider on Wednesday (weekly batch and queue method) and they do not get any confirmation back of what was received.  The woman that my wife spoke with was very nice.  She very politically said they know there is a problem and there was nothing she could do about it.  Basically, we have to now re-submit for reimbursement the manual way.  Send a fax to the flex plan provider with the Explanation of Benefits.

How much of this sounds like the place you work at?  A very common failure point is at the handoff point.  Passing information and work from one person to another.  This is exactly where the failure is happening in this case.  Could the handoff errors be caused by the batch and queue method of sending claims all over at the same time on Wednesday?  Could this overload the computer system and cause claims to disappear?

Does the insurance and flex plan providers really have the consumer in mind?  If they did, I would think they would be more willing to work together to solve the problem and help consumers.  Instead, they point the finger at each other and the problem continues, causing headaches for the consumer.

Finally, the woman working for the insurance provider is the closest to the problem because she hears from the consumers directly.  She told my wife they know it is a problem but they aren’t going to do anything about it.  The insurance provider does not even have a stop gap or rework loop.  They put it all on the consumer to manually refile directly with the flex plan provider.  Would you agree that she is not empowered to make change or even suggestions?  If the woman was empowered to make change she would have mentioned what action was being taken.  Instead, she made it sound like she can’t take action because the company won’t let her.

Wouldn’t the insurance provider’s cost be less if this problem was fixed?  Wouldn’t they need less call center people answering phones?  Maybe they could be working on other improvements to the system?  Maybe the benefit pre-approval area is swamped and could use the resources to help out?

The biggest thing that irritated me wasn’t the existence of a problem, but rather they knew it was a problem and sounded helpless to do anything about it.  That sounded like the sentiments I hear every time I go to a new area to conduct a kaizen event and try to engage a new set of employees.  They can say the industries are different but the problems look the same to me.

Collaboration Paradigm

I am a big fan of Fox’s TV show HOUSE.  As I was watching, I couldn’t help but think the medical team was participating in a kaizen event.  The concept that struck me was watching the doctors collaborate in the diagnosis of a patient and how this is just like breaking down the functional silos in a business environment.

Reaching across functional silos and collaborating has become more prevalent in today’s manufacturing world.  Manufacturing must collaborate with procurement and transportation in order to create a better total cost system that delivers value to the customer.  It has not been easy and it has not been the norm in the past, but there is still an abundance of examples to point to showing the benefits.

Why don’t more doctors work in collaborative teams?  The team on House all have different backgrounds and specialties.  This gives them all different perspectives on the situation (like transportation, procurement, and manufacturing) with one common goal……..save the patient (deliver a quality product to the customer when they want it).  At some point, if you put different doctors in one room and have them discuss the issue with you, it would seem that you would get to a true root cause quicker and I would suspect the cost would be lower instead of doctors working in their specialty silos.

Have you ever gone to the doctor when something is wrong and they sent you to a different doctor that is a specialist?  Then Specialist A runs all his test and claims nothing is wrong, so he sends you to Specialist B.  Specialist B runs his test and says your are fine and this goes on for what seems like an eternity.  Finally some doctor tries something and it maybe it works and maybe it doesn’t.  Is it just helping the symptom or is it the root cause?

Having doctors work in collaborative teams would seem to have the patients best interest in mind and create a stronger health care system.  I know we wouldn’t want to set up the  health care system to do this for every problem.  We could develop standardized work that would state when to call together a team of doctors and when to have doctors work individually.

We have torn down a part of the collaboration wall in manufacturing.  Can we start to tear down that wall with doctors?