Interested in Improvement Work in Developing Countries? On Call with Dr. Patrick Lee

Image linked from www.elpasotexas.gov

Interested in improving the quality of care in a developing country but not sure how to get started?

Curious about how effective, lasting improvements are made in rural, resource-poor settings?

Then join us for the next On Call and hear the story of how Dr. Patrick Lee and his teammates helped make dramatic improvements at a hospital in Kirehe, Rwanda. Dr. Lee, a volunteer clinical mentor for Partners in Health, recently finished a residency in internal medicine and primary care at Massachusetts General Hospital.

You’ll learn how Dr. Lee and his team prioritized their improvement goals, overcame the lack of resources and infrastructure, and built staff consensus and trust. You’ll also discover how you can apply the team’s learnings to your own work in a developing country or right here in the US – whether you are in a clinical or non-clinical setting.

Featured Speaker: Patrick Lee, MD
Event Date: Tuesday, January 27, 2009
Event Time: 4:00 - 5:00 PM Eastern Time
3:00 - 4:00 PM Central Time
2:00 - 3:00 PM Mountain Time
1:00 - 2:00 PM Pacific Time

Click here to register!

This free call is part of a monthly audio conference series that brings experts in health care improvement together with students from medicine, nursing, dentistry, pharmacy, health care management, public health, and other allied health professions. Each hour-long call is moderated by a student, ends with a question-and-answer period, and focuses on an issue that affects you. Visit our website to download audio files or written transcripts of past On Call audio conferences.

Hope to see you all on the call!

Health Care Reform Reading List

This past Saturday, I attended a health care conference hosted by the Harvard Business School Healthcare Club. In the Public Policy panel, John McDonough, Senior Advisor to Senator Ted Kennedy on Health Reform, and others shared with us their thoughts on the current atmosphere for health reform. They all agreed that we have the potential for change and that all the players are in place, but it won't be easy. This is the fifth time we've had a national debate on health care and it probably won't be our last. John McDonough shared with us an essential reading list to understand health care reform. This includes:

• The System: The American Way of Politics at the Breaking Point by Haynes Johnson and David Broder


• Critical: What We Can Do About the Health-Care Crisis by Senator Tom Daschle


• Senate Finance Committee White Paper "Call to Action: Health Reform 2009" by Senator Baucus


• Congressional Budget Office Reports on Health Reform

Have any of you read these papers or books? I myself have just picked up The System, which details the health reform efforts during the Clinton Administration. Thoughts? Comments?

Getting Lean at MIT, Part 2

I just learned about an idea so phenomenally, immediately useful that I felt the need to share it. The idea is called value stream mapping and analysis, and typically it reduces production time (for anything – a paper for Literature 1A, a Rolls-Royce, a successfully administered medication) by 75 percent.

Essentially, what you do is write down every single step in a given process, using a flowchart-style diagram. Then you identify the steps that add value to the customer. Here’s how you know if a step adds value:

1. The customer cares about it.
2. The item being produced changes in some way.
2. The step is done right the first time.

When you do this, the time-wasters pop out at you in Technicolor. Bells sound, lights flash, etc. And you now have a better picture of what’s taking so darn long.

Here’s an example. I recently set up internet service for my home (I’m not going to name the company, but it rhymes with Berizon). What’s the company’s process? In my case, it was something like this:

Step 1: I place the order by phone on a Friday. (10 min)
Step 2: Customer service rep (Jackie) receives and files order. (3 days)
Step 3: Jackie calls and schedules a time when Ray, the technician, can come to my house. (10 days)
Step 4: Does Ray go to the right house at the right time? If no, back to step three.
Step 5: Ray examines the wiring at my house. (30 min)
Step 6: Is Ray properly skilled and equipped with the right tools for the job? If no, back to step 3.
Step 7: Ray notifies Jackie, in the home office, of the need for a new work order. (15 min)
Step 8: Is Jackie in today? If no, back to step 3.
Step 9: Jackie approves work order. (2 hours)
Step 10: Ray sets up internet. (15 min)

In this process, which steps actually added value for me? I’d say Step 1 and Step 10 – a total of 25 minutes’ worth of work. In between, there were examples of pure waste (for instance, Ray went to the wrong house) and steps that didn’t add value but were necessary (Step 3).

I’ve charitably made this process only ten steps long. It actually took me about a month and a skillion, jillion phone calls before I could watch “Star Wars: Retold” in the comfort of my own home. If Berizon made a process map of all the steps required to install internet at my house, do you think they’d quickly find ways to reduce their cycle time (the time that elapsed between the order and the delivery of the product)? I think yes.

The applications of process mapping for health care are obvious. Instead of a customer requesting internet service, think of a man who shows up at a crowded emergency department with chest pains. Or a woman with poorly-controlled diabetes who doesn’t have a car to get to her appointments. Or a patient whose insurance company promises to pay out a claim but takes months to do it – giving the patient a choice between paying the enormous bill or watching his credit rating drop into the toilet.

To learn more about process mapping and related ideas for system improvement, check out the Lean Enterprise Institute's website – full of good ideas and resources.

(Many thanks to Dick Lewis, Earll Murman, and Annalisa Weigel, who allowed the IHI Open School team to observe their class on Lean at MIT today.)

Getting Lean at MIT

I spend most every weekday morning in a panic. I shower, throw on clothes, shovel in some breakfast, and frantically gather my wallet, keys and phone before running out onto an icy sidewalk -- and even then I'm generally at least five minutes late.

Today, a few members of the IHI Open School team went to MIT to learn about "Lean" - a production practice that seeks relentlessly to eliminate waste. Lean came out of Japan's post-WWII auto industry, but it has broad applications for practically any sort of production (including the elaborate production that is my morning routine).

Lets take a look at a Lean practice called 5S: Sort, Straighten, Scrub, Standardize, Sustain.

SORT: My alarm goes off and I knock over two glasses of water and a couple of books trying to hit the snooze button. I end up throwing out a sodden issue of Wired Magazine. I ought to SORT through the items on that tabletop and get rid of what's not needed.

STRAIGHTEN: My clothes aren't organized in any systematic way, and I spend a lot of time visually searching for what I need. When I STRAIGHTEN out my closet by putting things in bins, I save time.

SCRUB: I didn't do the dishes last night, and now I have to spend precious time rinsing out a cereal bowl. Last night I could have SCRUBBED the dishes and made them ready.

STANDARDIZE: I lose five minutes running from room to room, looking for my keys. I could create a STANDARD place for them - say, on the hook by the door -- so I'll never search again.

SUSTAIN: Here's the challenge. Once I decide on these changes, I need to SUSTAIN them over time.

Okay, so that solves my morning mess. But Lean is a lot more than a way to get yourself to work on time. It's a way to cut waste from any process - defined as a set of actions that transforms an input into an output. Whether the output is a chem problem set, a healthy patient, or a Toyota Prius, lean production requires you to sit down and understand key processes, noting which steps add value and DON'T add value for the customer.

So how to apply these principles to a system as big and complex as health care? Start by checking out "Going Lean in Health Care," a free white paper from IHI.

Third Grade Poster

Today is Inauguration Day. I have never seen so much excitement from everyone on Inauguration Day before. Words like "renewal", "hope", and "change" are on everyone's lips. Barack Obama's Inauguration is openly being compared to JFK's Inauguration and FDR's Inauguration. But, because I wasn't alive then and don't have the privilege of time travel, Obama's Inauguration reminds me of a very special day when I was in third grade.

One day, Ms. Kozak, my third grade teacher handed out large sheets of poster board and placed boxes of markers on our desks. She asked us to create a poster to celebrate Martin Luther King Jr. Day for the Palm Beach County Martin Luther King Jr. Day Poster Contest.

We all diligently went to work on our posters. Now, I had and still have little artistic skill. My sister is actually the artist of the family. She could draw Disney's The Lion King characters before she knew how to describe them in words! Most of my classmates drew remarkable portraits of Dr. King. After about an hour of doodling, here's what I managed to put on paper (a shoddy electronic 2 minute remake- not the actual poster):



A few weeks after Ms. Kozak collected our posters, she announced that the winner of the poster contest was in our class! I knew it had to be Sean because his portrait of Dr. King looked just like a photograph. But, I was wrong. Ms. Kozak said my name! I was to go to Pine Grove Elementary School on Martin Luther King Jr. Day to attend a celebration and accept a certificate!

I was so proud. As I walked out of the classroom at the end of the day, Ms. Kozak handed me a letter to give to my parents. She said in it included more information about the Martin Luther King Jr. Day celebration. When my parents opened the letter that night, my mom told me that maybe it would be too dangerous to go to the celebration.

Dangerous? Third grade for me, was 15 years ago. And 15 years ago, Pine Grove Elementary School was an impoverished public elementary school located in the heart of an economically depressed community. The area was frequently on the news making headlines in crime. Generally, it was an area that most people tried to avoid. But, after some thought, my parents decided that it was important for us to go.

On Martin Luther King Jr. Day, I put on my favorite moon sweater and wore my brand new white cowboy boots (fashion is also not one of my strong suits). I was ready for this big day. We drove to Pine Grove Elementary School and my parents were visibly nervous. We checked to make sure our car doors were locked twice before leaving the car and took out anything valuable. The mood, however, changed drastically as soon as we stepped into the gym for the celebration. The gym was brimming with people. My memories of the ceremony are a bit fuzzy now. But there is one moment that I will never forget.

When I was called up to the podium to stand next to my poster, I was greeted with a standing ovation. The audience was at least 70% African American and everyone was wearing their Sunday best. I will never forget the feeling of standing in front of such a large audience of strangers of all different races and backgrounds cheering. For those few seconds we stood together not to celebrate a poster, but to celebrate the message of peace, equality, and a shared humanity-- Dr. King's message. For those few moments, Pine Grove Elementary School was not a place to be feared, but an oasis to be envied.

An Obama Cookie!

Barack Obama is now the 44th President of the United States. It may have taken us 46 years since Dr. King shared his dream, and 15 years since my third grade poster, but our new President has accomplished the dream. In his inaugural address, President Obama said:

For we know that our patchwork heritage is a strength, not a weakness. We are a nation of Christians and Muslims, Jews and Hindus - and non-believers. We are shaped by every language and culture, drawn from every end of this Earth; and because we have tasted the bitter swill of civil war and segregation, and emerged from that dark chapter stronger and more united, we cannot help but believe that the old hatreds shall someday pass; that the lines of tribe shall soon dissolve; that as the world grows smaller, our common humanity shall reveal itself; and that America must play its role in ushering in a new era of peace.

Today is not just a momentous day for the minorities in America, but for everyone.

If I could draw a poster (this still comes with great difficulty) that embraced my dream for health care, here's what it would look like. It would take place in my dad's doctor's examining room. My dad would be facing the doctor. My mom, my sister, and I would be standing off to left of my dad. A nurse would be standing right next to the doctor. The nurse would be holding a few pamphlets ready to give them to my dad. The doctor would be pointing to a diagram of a foot displayed on a computer screen with his right hand. In his left hand, the doctor would be clutching a clipboard detailing a health regimen my dad should follow. A clock would be noticeably absent from the poster. And most importantly, we would all be smiling.

Hopefully, that's what we will be celebrating in 15 years. What would your posters look like? Happy Inauguration Day!