| 19 June 2015
Dear Interested Readers,
Inside this Week's Letter
I half expected that we would hear the Supreme Court’s decision in King v. Burwell this week and as you read this letter it may have happened between Thursday night when it was written and whenever you read it.
What is in the letter is a review of the similarities and synergies between Lean and the work of Dr. Tony DiGioia’s team that has developed the Patient and Family Centered Care Methodology and Practice. In the second section I answer a question posed by Rob Jandl who always has the ability to raise the concerns that many physicians feel but often do not express.
I hope that you are visiting strategyhealthcare.com as a weekly habit and I want to welcome a couple of new interested readers who signed up this week for this letter on the strategyhealthcare.com website.
A Proposal For Marriage
Last weekend I received the following email from Dr. Tony DiGioia who is an exceptional orthopedic surgeon and the founder of the Patient and Family Centered Care Innovation Center at the University of Pittsburgh Medical Center.
Hi Gene,
Awhile back, I had mentioned that we have been working with several Lean based/process improvement focused organizations in leveraging the best of Lean with the best of PFCC in order to achieve the Triple Aim. We recently had this article published that shows the synergies between the approaches and how they can compliment each other.
In fact, this theme (my nickname - Lean Meets PFCC) took root when I met you and thru your work at Atrius. The effort began in earnest after you introduced me to Tanya and we then presented the two PFCC VisionQuest workshops for the Leadership Academy….so again you were the “catalyst” for efforts to redesign care delivery.
I hope the article is helpful and please let me know if you have any suggestions as we continue this effort.
As always, best wishes,
Tony
Tony’s comments are kind but his memory is a little faulty to my advantage. It was Tanya Chermak [who like Tony is an “Interested Reader”] who introduced me to Dr. DiGioia. I will confirm that from our first meeting that occurred in the Copley Square Starbucks on a Saturday morning during one of his trips to the IHI, I have been fascinated by his work and the synergy that I have appreciated between his ideas and Lean. As I sat there on that chilly midwinter Saturday morning trying to warm up my fingers by embracing a Grande French Roast, I was saying to myself, “This man is a Lean thinker!”
His work begins in the true gemba and with the experience of the customer as its primary reason for being. Back at Atrius, Tanya, who was then leading the Leadership Academy, and I continued the conversation about the synergies between Lean and Tony’s ideas and methodology. It is possible that Zeev Neuwirth, now at Carolinas Healthcare, also deserves a shout out. Zeev was the founder of the Atrius Leadership Academy. Zeev was always on the lookout for innovators like Dr. DiGioia to invite to speak at the Academy and perhaps it was Zeev who originally identified the Patient And Family Centered Care Methodology and Practice as something that we should introduce to our leadership in the training program.
No matter what the details of the serendipity might truly be, “Lean Meets PFCC” is now in the literature with the publication by Tony, Tanya, Pamela Greenhouse and Margaret Hayden of:
A case for Integrating the Patient and Family Centered Care Methodology and Practice in Lean healthcare organizations.
This article appeared recently in Healthcare: the Journal of Delivery Science and Innovation, which is where I recently published my review of Patty Gabow’s fantastic book The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System. I do not know if there is a connection but since the paper by Dr. DiGioia went to press I have been invited to join the advisory editorial board of the journal to help with articles that focus on Lean.
Realizing that you have too much to read I will give you what are some of the high points of the paper and remind you that just two weeks ago I recommended your attendance at a one day conference that Dr. DiGioia and his colleagues are presenting in Pittsburgh in September. As I said on June 5:
The conference is entitled Co-Creating Health: Technology and Process in a Digital Age. It will be on September 18 in Pittsburgh. More information is available at www.DeliverValue.org. I do not usually make recommendations of this sort but I believe this will be an informative and useful conference and that many “Interested Readers” will be glad they attended.
With those introductory remarks, let’s take a close look at the paper. It begins by noting that:
The two main reasons [for the consideration of PFCC and Lean together] are to address the challenge of keeping the patient (and family) as the primary focus of improvement activities and to add ‘patient experience’ as an equal focus with eliminating waste. While conceptually “patient first” is the process driver in Lean Healthcare organizations, some healthcare organizations find this to be a challenge in conventional, real world Lean implementation.
From there the paper describes the central ideas in Lean and presents evidence of how PFCC M/P (Patient and Family Centered Methodology and Practice) augments and can catalyze Lean process improvement. My thought has been from my first hearing of the PFCC M/P that there were more similarities than differences between the two techniques and that they could be used together to make both more effective. I think this point is of extreme importance because Lean tools alone are necessary but insufficient for a clinical transformation and the methodology of PFCC M/P may be considered by some to be attractive but they may find it does not cover the whole enterprise with the same intensity that Lean attempts. For those who may be reluctant to accept Lean because it feels like a “manufacturing” process, the combination of PFCC M/P and Lean may offer an opportunity to present Lean in a way that lowers their barriers to participation and more directly aligns their natural concerns about the patient with an effective introduction to continuous improvement thinking and methodology.
I really like one of the early statements in the paper about Lean as the authors begin to discuss the similarities and differences between the two techniques:
The central idea in Lean in healthcare is to improve the quality of care for patients, the ultimate consumer, by eliminating waste and inefficiencies (with a zero defect goal) [that is a little Six Sigma thrown in for good measure] using these core Principles:
- Identification of customer value;
- Management of “value stream”;
- Developing capabilities of flow production;
- Use of “pull” mechanisms to support flow of materials at constrained operations; and
- Pursuit of perfection through reducing to zero all forms of “waste”.
Many Lean stalwarts would point out that the statement misses “respect for those doing the work and their participation in the process of continuous improvement” as two of the keys to its effectiveness. I say this only because those points are actually shared with PFCC M/P. It is important to realize that in the paper the authors are working toward common ground and broader acceptance of shared ideas and not trying to use one methodology to trump the other. My own description of Lean would also have included in addition to the focus on respect, the realization of a need for a cultural transformation that is much deeper and more profound than the five point description implies, but again we are moving toward a shared interest in creating value for the customer when we bring Lean and PFCC M/P together.
As I worked my way through the paper, I was underlining thoughts in almost every paragraph. It is a tightly constructed paper and there are many “jewels” in it. After reviewing their view of the core principles of Lean, the authors do a wonderful job of presenting the history, methodology and principles of PFCC M/P. The technique has evolved at UPMC since 2006 and has been adopted by dozens of healthcare organizations nationally and internationally. It is important to note that UPMC is a large and complex health system with an academic medical center at its core.
There are six steps to the PFCC approach which views all care experiences from the view of the patient and the patient’s family. Like Lean, the methodology is careful to describe the “current state” and the “ideal state”. Taking a step back I would say that the universal “reason for action” is the realization shared by PFCC M/P and Lean that care is fragmented, not designed with the patient (or family) at the center of the experience, and neither its quality or its cost is acceptable.
The key differences between Lean and PFCC M/P become evident when you begin to realize the care and the time that PFCC M/P invests in understanding the current state as the patient and family experience it. Lean “RIEs” at Atrius Health often included patients but in reality the staff described the current state, albeit as they tried to appreciate the process as experienced by the patent and family. The technique of “shadowing” or following one or more patients through the flow of a clinical process and making patients and their families “full partners” in the entire process, including the continuing review of the outcomes, is the key difference that I appreciate between most Lean programs, as currently practiced, and PFCC M/P.
“Shadowing” patients and families through their entire experience of care with a focus on what needs to change from the patient and family viewpoint is core to PFCC methodology. Shadowing is then coupled with the continuing participation of patients and families in the change process to guarantee that the sensibilities of the patient and family are present in the creation of the description of the target or ideal state and the work to make that vision the new standard expectation. By making the sensibility of the patient and family much more central to the process and outcome in 65 distinct clinical areas at UPMC, patient satisfaction, quality of care and cost have all improved.
There are 3 key points:
- View all care experiences exclusively through the eyes of patients and families.
- Engage patients and families as full partners in co-designing care.
- Provide simple methods within complex systems to overcome hurdles and break down barriers to providing ideal care delivery.
Their last key point is, in my opinion, the cross over back to Lean tools and culture. I quote the paper:
“The PFCC M/P creates broad teams of caregivers from every function and level of the organization who work together to close the gap between the current and ideal care experiences. These cross functional teams break down the existing silos pervasive in healthcare settings to create high performance care teams focused on transformational change.”
The paper then describes the six steps to the process:
- Select a care experience.
- Establish a 3-4 person PFCC guiding council (Administrative and Clinical Champions and a Coordinator) [ Again, quite similar to standard Lean methodology and infrastructure.]
- Identify the current state through Shadowing and Care Experience Flow Mapping [much like going to the gemba].
- Establish a cross-functional and cross hierarchical PFCC Care Experience Working Group [ Again, ditto for most Lean projects even if they do not cross departmental boundaries.]
- Create a shared vision by writing the ideal care story from the patient’s and family’s point of view [the big difference].
- Form PFCC Project Improvement Teams to close the gaps between the current and ideal state of the care experience. [Similar to the way most Lean kaizen events are populated, plus the certainty of patient and family participation]
They note the similarities of this methodology to Lean and comment that both Lean and PFCC M/P seek to:
- Embed new ways of improving care into the DNA of the organization.
- Value is determined by the user (Lean does not explicitly consider the family as a customer, as the PFCC M/P does).
- They both are grounded in the science of improvement which involves testing and learning cycles.
- Both advocate going to where the work is done.
- Time studies and flow maps are used to define the current state.
- Both tap the power of cross functional (cross departmental) teams to fuel improvement.
One of the recurrent points that Dr. DiGioia makes is that for resource strapped organizations the PFCC M/P process can be virtually free. He and his colleagues are passionate about giving their ideas away. Their methodology and experience is well documented in many publications and the whole process can be easily understood from going to their website, www.PFCC.org which has more background information as well as free downloads for PFCC and “Shadowing Go Guides”. I hope that you will take a look, even though for some I know that “free is not cheap enough”. You will need to invest some time. The last important section of the paper before some case studies offers an analysis of where PFCC M/P might augment Lean. - With its focus on the patient and the family.
- Breaking down silos. [In my experience Lean also breaks down silos. Many of the processes that are improved by Lean are “within” a silo, like an EW or an operating room. Within Atrius some of our most significant accomplishments with Lean have been between two or more departments. I will agree however that from the start, from the patients and family centered view, almost all episodes and processes of care eventually cross silos.]
- Staff engagement. [Again Lean does this well when Lean is done well. You might remember my letter from a few weeks ago when my friend Doug described how he had experienced Lean within his practice. There was no real engagement, just the instillation of a Lean outcome done by executives and not the people doing the work.]
- The authors suggest that PFCC may contribute sustainability and transformation. [Their opinion seems to arise from the idea that Lean is transactional and not transformative. This opinion may coincide with observations in some organizations that do Lean but have not adopted a Lean culture and become Lean. My frustration is sometimes most acute in the balance between doing and being Lean.]
The paper ends by advocating more attempts to augment Lean with PFCC M/P in those organizations that are using Lean. One concrete suggestion was to integrate Shadowing into Lean. Another was prioritizing projects by what is important to patients and families. They suggest having staff identify what they care about and Shadow patients before doing Lean training. Finally they suggest using PFCC M/P stories and metrics at the daily MDI boards.
The conclusion of the authors is a strong vote for using both techniques together. Circumstances may determine how or which part is tried first. At this point I realized that I view Lean like I view the English language. Our language has a richness that has evolved by taking words from other languages from around the word and across time and other barriers. It is constantly evolving and becoming richer even as it retains much of its form and grammar. The form and grammar are changing more slowly than the words but it is the rapid addition of new words in the context of the slowly changing grammar that gives us the greatest powers of expression for abstract ideas. I think it would be great if more Lean organizations did try adding the lexicon of PFCC M/P to their Lean grammar. I hope to be among the family and friends of the happy couple at the wedding of Lean and PFCC.A Good Question
I have mentioned my respect for Dr. Rob Jandl before. Rob was the chief clinical lead in the Atrius Health Pioneer ACO strategy. He is a PCP’s PCP. He is always thinking about what might be better and has a deep and abiding concern for his colleagues. He is constantly thinking about how to make the practice better for those who receive care and a more meaningful experience for those who provide care. Rob leads by the effective use of “inquiry”. His questions are always challenging and I often realize that he has the insight and courage to ask the questions that are on the minds of many who chose not to speak. This week he wrote me to ask a very good question. I appreciate his willingness to allow me to share his question with you.
Hi Gene,
Our new morning newspaper guy arrives late these days so I found myself catching up on your weekly letters both this morning and yesterday morning over breakfast. What a feast. Among other things I was very taken with the triple aim discussion and liked your longer view non-dystopian outlook of hopefulness and opportunity. Here is a piece I have been struggling with and would appreciate your thoughts: Personally, I can envision work that will get us to a better place around quality, the health of the population, as well as the experience of care. Those we can execute around aided by payment reform moving towards value. However, the cost of care is more nettlesome. Setting the bar very high, the IHI has set its sights not on bending the rising cost curve but on truly lowering the cost of care per capita and would return those dollars to the community so they can be used for other priorities.
It is here where the noble vision clashes with the business realities. Even in a capitated world I can preserve margins by lowering the cost of care (and I believe that in general lower cost equals better quality and patient experience, all good). I might even wish to provide my providers a bonus for their hard work to preserve motivation and a happy work environment. Absent that, am I to accede to the payers, reduce our fee schedule, and let them have their way with the savings? If I am to advocate for taking the high road and commit to a path that will likely reduce revenue to the group and therefore, all else being equal, compensation to providers, and actually executed that, how would those monies be returned exactly to the community? What reassurance would we have that the greater social good would actually improve on account of our sacrifice? I understand and like Paul's [Levy] critique of usual business practices such as hospitals building edifices that deliver no great value to patients--what a waste of resources--and yet the path to breaking free of continued efforts to control the market and leverage power is difficult to envision.
I do have one idea, albeit somewhat limited, that being the better use of foundations linked to the mothership. In the cases of Reliant or Atrius, both have foundations that could in part be funded with saved dollars with those dollars then used to invest in the community. We know that roughly 80% of healthcare outcomes are determined by factors outside the medical delivery system (water, food, exercise, socioeconomic status, etc.) Not a new thought for sure but this way we have a vision for how to better link lowered cost of care with healthier communities writ large as improved health of the public in part emanates from improved education, jobs, food supply, etc...
What are your thoughts on how to lower the cost of care while maintaining a viable business system and productive workforce?
Warm wishes,
Rob
My answer to him will perhaps reveal my own misunderstandings but here is what I said:
Rob,
There is an answer to your question.
First, no one I know is advocating for lower compensation for most physicians, especially Primary Care physicians.
I would suggest that you read Atul Gawande’s article in the May 5 New Yorker entitled “Overkill”. He goes back to McAllen, Texas and looks at what happened after the publication of the 2009 article that put the spotlight on the waste. Through waste reduction and the MSSP ACO primary care compensation is actually up while Medicare TME is down a lot.
The answer lies in the operating system and in the standard work of physicians. Larger panel sizes managed with team based care by physicians with a different mind set and a different standard work can both lower the cost of care by reducing the waste from “overkill” as Atul describes it and by expanding the effectiveness of physicians as leaders of teams. As long as compensation is tied to RVUs rather than population metrics you are right, there is nothing but pain ahead for you and your colleagues. My whole misunderstood mission at Atrius was moving us to a totally capitated practice [or at least have a majority of revenue coming to us through Alternative Payment Methods, APMs] where we could disconnect compensation from RVUs and connect it to quality and population metrics. Doctors have only pain ahead without some reengineering of workflows and compensation for value creation. You are doomed in a FFS practice to run faster and faster for less and less.
I hope that this helps,
Gene
I am sure my answer will be read by most as an over simplification of an extremely complex and worrisome reality for doctors, but let’s be realistic. Doctors are essential to any process of care delivery. That makes the possibility of a reduction in their compensation less likely in a market based system as their is a growing shortage of physicians relative to the growing needs of the population. Some physicians are feeling burned out and are leaving practice because their “standard work” is not what they really want to do. I frequently ask physicians how much of their time do they spend doing what they want to do and what they trained to do. The average response is about 33%. When I ask them what they think they should be doing almost all of them give me the same answer which is spending more time with patients.
The doctors in McAllen were called out by transparency that they did not want, but the response of many was to change their standard work and embrace team based care and to begin to practice in the environment of population health utilizing team based care. Our current focus is on finance and lowering TME. Patients, employers and governmental payers and taxpayers will find better places to spend the money they retain when premiums and charges fall or do not rise relative to their local economies.
The pie chart that shows where the healthcare dollar goes has many components. The part of the dollar that relates to compensation for physicians, nurses and everyone that is working hard in healthcare is much smaller than most people realize. At present we are gaining our savings from the 20-25% of the dollar that is related to hospitalization. There are other dollars to be saved in the process of care as Gawande’s article on “Overkill” demonstrates. Innovation and new technologies have the potential of greatly reducing the cost of care.
I have quoted Dr. Ebert hundreds of times but I will do it again:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Dr. Ebert understood that the system was the issue. It was in 1965 and it is sadly true 50 years later. Rob is concerned, and understandably so, about the impact of change on physicians and their work life and compensation as we are “organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.” I am much more concerned about the income of physicians and their work life satisfaction if we do not transform healthcare and change the way they work. I am even more concerned about what will happen to patients and families and the physical and fiscal health of our communities if we do not continue in our efforts to solve these problems.
Walks Through History
I like nothing more than a walk where things have happened. One of my sons went to Gettysburg College back in the nineties when I was more of a runner than a walker. Every time I visited him I took a long run on the battlefield. I would jog past the Devil’s Den, Little Round Top, Cemetery Ridge, Seminary Ridge and even pause and look across the wide expanse of the cornfield where Pickett led his charge and over 6000 men, some of whom were from North Carolina and a few of whom were distant relatives, died in a futile attempt to recover from the bad decisions of the previous two days.
Whenever I come to Washington I spend time walking on the National Mall. If you swing above the Capitol where the dome is now obscured by scaffolding and then continue around past the Supreme Court Building , the Library of Congress and the Congressional Office buildings down to the Mall and past the Washington Monument toward the Vietnam Memorial and around the Lincoln Memorial and then back up to my hotel not far from Union Station, you will have walked over six miles. Wednesday evening was a little overcast and there were intermittent showers yesterday evening. The weather did not seem to make a difference to the thousands of residents and tourists who were walking, jogging, or laughing and playing on the grass and walkways of the Mall with their friends. On both evenings all of the available grassy areas were crowded with young people playing softball, kickball, soccer and ultimate frisbee where once people were camped out in Resurrection CIty five years after tens of thousands had stood to hear Dr. KIng give his “I Have a Dream Speech”. The same grass was where the Million Man March was yet another expression of our freedom to assemble. The Mall is surrounded by Museums and Federal Buildings but it is also the site of many historic events in our struggle to understand how to live with one another.
There is a lot to occupy your mind and eye as you circumnavigate the expanse of the Mall. The Mall is in a process of repair and I am glad to see it because like much of our nation's infrastructure there are some blemishes on its beauty. On this trip I was particularly moved as I watched crowds at the Vietnam Memorial and discovered that at almost 8 PM the Martin Luther King, Jr. Memorial was still crowded with people from all over the world. His statue is magnificent but the quotes from him carved in the stone of the surrounding walls are what really demand our attention. His wisdom will endure forever and will survive the monument.
I chose a picture that I took of the Supreme Court Building as this week’s header. As I walked by I imagined that inside some law clerks were cleaning up the typos in the final language of the decision in King v. Burwell that may have been announced by the time you read this note or will surely be known within the week. I have decided that even though it will be a shame if the court denies the subsidies to over 6 million recipients in the exchanges now run by the federal government for the states that did not care enough to do it themselves, we will not go backwards. I am encouraged by what I have heard this week from people from all over the country who have gathered for the ACO Summit. I will give you a complete report next week. In the interim, no matter what the Supreme Court says, be like all the people on the Mall and get some exercise. |
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