Hidden Healthcare Capacity — learn from lean manufacturing

Healthcare in the past has shunned “conveyor-belt” surgery, “cookie cutter” treatments and “cookbook medicine”.  But, the disdain for efficiency, as honed by manufacturing, has put the spotlight on medicine and surgery as very inefficient with a huge hidden or wasted capacity.  Patients and healthcare providers are asking for the training of more healthcare professionals — they can’t manage the wave of baby-boomers needing care or the influx of new patients using the methods of the past.   So, let’s not use the methods of the past, it’s time to learn from industry, from Toyota, from Ford.
The key principle is “lean” —  definition of Lean, as developed by the National Institute of Standards and Technology Manufacturing Extension Partnership’s Lean Network:

“A systematic approach to identifying and eliminating waste through continuous improvement, flowing the product at the pull of the customer in pursuit of perfection.” 

Here is a translation for healthcare:

“A systematic approach to identifying and eliminating waste through continuous improvement, providing health care as needed by the patient in pursuit of perfection.”

 Here are the 8 “wastes” to be eliminated, as might be applied to a medical office:

• Overproduction — From a medical office standpoint this is excess staff at certain times — indicated by an appointment schedule that is not full.  Staffing must be adjusted to patient load.
• Waiting — Patients waiting for appointments, providers waiting for test results.  Ideally the when patient arrives  the provider is ready to begin.  Needs to be monitored with visual controls all the time.  Solving patient problems on the phone prevents clogging the system with unnecessary visits and reduces excess inventory.
• Transportation — equipment (like gowns and syringes) need to be at the point of use not transported around the office.
• Non-Value-Added-Processing (reworking) — having to review patient data because the problem was not resolved initially.  Sometimes multiple workers collecting the same information (very common when patients are admitted to the hospital) And, excessive medical documentation, a common problem with speech to text systems.
• Excess Inventory —  No room in the appointment schedule because it is all filled up, patients want to be seen but no staff are available.  Represents a failure to hire adequate providers and staff.  Larger organizations are better able to make staff flexible, like sending them to a branch office if several staff are missing due to vacations or illness.
• Defects (do it right the first time) — Following evidence based guidelines and using checklists reduces error in treatment and diagnosis.  Errors may result in legal action.  But, less severe errors end up requiring correction or at least explanation.
• Excess Motion (poor workflow and documentation) A huge problem.  If offices don’t have labs, x-ray, a pharmacy, physical therapy, and commonly needed specialists it causes wasted patient and staff time.
• Underutilized People — offices don’t often let nurses or scheduling departments make common sense changes.  Small offices fail to hire computer consultants or patient educators.

Much of the waste currently is due to lack of scale for many providers — they just don’t have big enough facilities.  Also, on a larger scale many towns have excess capacity in certain specialties.  Like supporting one neurosurgeon when all the neurosurgery should be done at a regional center to keep the providers busy and competent.  Likewise, not every hospital should be a high level trauma center.  Not every town or hospital needs a cancer treatment center.

Simply treating more patients over the phone is probably the greatest method to find hidden capacity.  If a visit is just to consider a blood sugar record that can be done without an office visit.  The second best efficiency boost is to incorporate NPs and PAs as team members.  Third, a high functioning computer record helps to prevent reworking and reduces excess motion.  Above all, constant monitoring of efficiency and quality with continuous improvement is essential.

Waiting for Care — getting worse in the U.S.

Elisabeth Rosenthal’s article in the New York Times 7/5/14 “The Health Care Waiting Game” again puts the spotlight on US health care.  This time she points out a problem everybody has been experiencing:  long waits for health care appointments.  The average wait for a family practice appointment is about 20 days with extremes across the country from 5 days in Dallas to 66 days in Boston.  Examination of the private sector begins to make the VA look better.  The question now:  how many people have died waiting for appointments?  (it’s a no brainer — lots)

While wait times in the US have gotten longer they have gotten shorter in other places in the world like the UK.   To some degree the acute problem is an influx of newly insured people into the US market.  But, long before the acute problem there has been a chronic decline.

From an economic point of view it’s all supply and demand (see “Principles of Health Economics“) .  Economists point out that the demand for healthcare is almost infinite whereas the supply is always going to be limited.   At some point a line must be drawn.  Is $100,000 per year for a medication acceptable?  Is $500 for a “wellness”exam too much?  Do we really need MDs to treat diaper rash?

Long waiting lines are a sign of poor management.  If a person can’t be evaluated by the healthcare system there is no way to know what is being overlooked.   Perhaps that person in the line only needs a cheap generic medication; not everyone is waiting for hip replacement surgery.  As a country we need to get the best bang for the buck and use limited resources wisely.

We seem to be wasting time coming to grips with healthcare problems.

“I wasted time, and now doth time waste me.”
― William Shakespeare

So, what can a patient do?

• accept appointments with providers that are farther away
• accept PAs and Nurse Practitoners for follow-up and simple problems
• do your part to learn about your health problems so you don’t drag the system down with poor healthcare literacy
• complain about high prices and long waits and vote for better health care regulation, not less.

 

Real Life ER Visit — Some Pitfalls

One winter afternoon Mr. C was at his health club  enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed.    In the past, any nosebleed would go away with some pressure but this was different, the bleeding  just would not stop.  Driving his car was out of the question.  Fortunately, another health club member offered him a ride to the ER.  On the way they passed an urgent care clinic but did not stop.  They were concerned the urgent care clinic might not be able to stop a nosebleed.   The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.

Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room.  After 20 minutes a nurse evaluated him and took his blood pressure.  His nose continued to bleed and 30 minutes later a doctor arrived.  He put drops of epinephrine in the nose followed by a nasal pack.  The bleeding stopped, he was given an antibiotic  pill (ciprofloxacin), he  rested a few minutes then his wife took him home.  A few days later his wife removed the packing as directed.  Problem solved — at least the bleeding problem.

He eventually got a statement from his Medicare (MC) supplemental insurance company.  

Item	Charges	MC Allowed	Out-of-Pocket
Facility charges	$3,569.05	$310.92	$0
Procedure (30903)	$681.00	$139.85	$0
epinephrine 4 drops	$204.60	$0 *	$204.60
ciprofloxacin 500mg	$50.82	$0 *	$50.82
TOTAL	$4,505.47	$450.77	$255.42

* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge.  What Medicare does not allow supplemental insurance will not allow either.  So, the patient has to pay.

Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55   (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45                       (charged 110 x cost)

See the reference on nosebleeds (epistaxis).

Could there have been another way?  Less waiting and less cost?  Perhaps.  Consider the following alternative scenario:

A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP).  The patient was instructed to go to an urgent care center.  Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on).   The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50).    The charges and out of pocket expenses for the urgent care visit were as follows:

Item	Charges	MC Allowed	Out-of-Pocket
Procedure (30901)	$275	$94.32	$0
epinephrine nasal	$20 (est)	$0	$20.00
ciprofloxacin 500mg	$0.50	$0	$0.50
TOTAL	$270.50	$94.32	$20.50

It is important to note there is no “facility” charge at the urgent care.  Only hospitals can charge for use of the facility.  Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies.  In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.

The bottom line:  At your next visit with your PCP discuss how they want you to handle minor and major emergencies.  In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room.  Use urgent care centers rather than the ER if possible.  Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy.  If your PCP is aware of an urgent problem they will likely follow up when needed.

Observation Unit — Between ER and Hospital

Laura Landro of the Wall Street Journal reported on a growing trend in US hospitals.  The trend is the “Observation Unit”.  In hockey terms it is the penalty box where hospitals put patients they can’t send home but can’t admit, at least for a few hours.

The origin of this idea may have come from English hospitals.  Those hospitals run at almost 100% occupancy.  So, when a patient from the ER needs to be admitted there is a delay to wait for a room.  Those patients  get put in a big room next to the ER with several gurneys, a few nurses,  and lots of curtains (the observation unit).  The patients do get tests and treatments but they wait for a room.  As it turns out, some of the patients get better and don’t actually get admitted — they go home — the rest eventually go to a hospital room.  In England hospital care is free and the hospitals don’t have to worry about insurance or Medicare rules that separate  outpatient and inpatient charges.

US hospitals have plenty of beds available but US hospitals do have to worry about insurance and Medicare rules.  Care is not free and if a hospital makes a mistake (like admitting for indigestion) they don’t get paid.  And, if a doctor makes a mistake and sends a patient home who should have been admitted (for a heart attack) they could be in legal trouble.  Consequently, unlike the English hospital that needs to hold patients to wait for a bed the US hospitals need to hold patients because of red tape and legal worries!  It’s hard to tell which is worse.

The Wall Street Journal article puts a positive spin on the “new” idea:  “when operated efficiently observation units have been shown to reduce health-care costs and improve treatment”.  Obviously there is a balance of forces between the Hospital that makes money and the insurance company that looses money with each admission.  Regulators try to develop rules to speed evaluation and treatment so some patients can go home safely without a hospital admission and the huge associated costs.  Any patient who can bypass the hospital will also avoid the risk of hospital errors and exposure to hospital acquired infections.

Patients have two main concerns:

1) Getting the right care the first time and not coming back sick.   The unit may provide a little longer time to get test results and see if treatment is working which is good unless unnecessary tests are being done.
2) Minimizing out of pocket cost.  A person without insurance would get a lower bill by avoiding the hospital but having both the cost of observation and hospitalization is a real possibility.   The current trend for insurance  is to shift a higher percent of outpatient charges to the patient compared to inpatient charges.  So, depending on what a person’s insurance covers, there might be higher out of pocket expense for using observation.

Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance	Points
When I call the office, who answers?
A real person	2
A computer answering system that connects to a real person	1
I know the office will provide appointments:
New patient appointments within 3 weeks or Follow-up appointment for new problem in 3 days	2
Urgent problem (during office hours) on same day	3
The office designates time for walk-in visits	2
The office has some evening and weekend hours	2
Moving through the office (assuming you were on time)
Checked-in within 5 minutes	2
Checked-in within 5 to 10 minutes	1
Face to face with the provider within 5 minutes of appointment time or within 30 minutes for a walk-in visit	3
Face to face with the provider within 10 minutes of appointment time or within 45 minutes for a walk-in visit	2
Checked-out within 5 minutes of leaving provider	2
Checked-out within 5 to 10 minutes of leaving provider	1
Provider visit
I do not have to take off clothes before seeing provider	2
I can sit in a chair at eye level with the provider	2
Provider seems to care about me	5
I am not interrupted while I say the reasons for the visit	4
The part of my body with problems is examined	3
The paper chart or the computer is just used by the provider to find information to help me	2
The diagnosis of my problem is made clear	4
I am directed to handouts or Internet sites about my problems	1
Before I leave, the provider asks if I have any other questions	3
It is clear when I need to return for recheck	3
Medication Management:
The reasons I need to take all medications are explained	3
My provider sends prescriptions by computer	2
Possible side effects of medications are discussed	1
At each visit I receive a list of my active medications	3
Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why	2
The office always lets me know test results within a week	2
I always get copies of test results	2
Practice environment
My provider has associates who substitute when needed	2
Hospital care is done by hospitalists	2
My provider is part of a system including specialists	2
Physician assistants or nurse practitioners work at the office	2
TOTAL POINTS  =

—

Score	Rating
60 and over	5 star
50 to 59	4 star
40 to 49	3 star
30 to 39	2 star
below 30	1 star

–

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

Excessive Waiting – You call that a schedule?

35% had to wait for an appointment with a doctor longer than thought reasonable.  Scheduling services is a difficult task in any business.  Restaurants have numerous employees that have to be scheduled in the face of day to day changes in business and generally do quite well.  Airlines schedule flight crews, aircraft and thousands of passengers every day with remarkable success.  However, a health care facility that runs on schedule is quite unusual.  The providers feel so much is unexpected they can’t follow a tight schedule (but on paper they create a tight schedule).  There are many reasons for this phenomenon but no excuse.  Schedulers can be tasked to optimize provider time or patient time and usually the former wins.

• For patients:  a primary care clinic should be able to see a patient with an urgent problem the same day, a bothersome problem within a few days and all patients who request within a week.  If that is not what you find then check out other clinics.  Be willing to see any one of the provider team for urgent problems.
• For providers:  constantly monitor the delay between appointment time and provider appearance time and adjust the master schedule accordingly.  Providers should work as a team.  A pool of providers needs to have open slots for urgent visits and other providers need to have uninterrupted time for scheduled visits.  The future is with patient self-scheduling, like booking a seat on an airplane – check what is available and book a time slot on the Internet with no phone calls!