If you work in healthcare, you know that some of the statistics are pretty staggering. Each year, thousands of patients in hospitals die or are seriously injured through errors — whether it’s through faulty systems, out of date surgical approaches, or medical process failures. But Dr. David Kashmer believes that there is a better way.
Dr. Kashmer designs and builds high-quality health care systems, using a data-driven approach. In turn, these proven methods and tools make our patients safer, our healing procedures more effective, and our costs lower.
In this episode, he talks about the current transition in healthcare, and why it is more important than ever to use the tools available to make significant improvements to the system.
For anyone who is passionate about improving our hospitals, this episode is for you.
What’s frustrated you about health care?
We have not routinely used a lot of the tools that can help take us to the next level of quality. They exist, they’re out there, they’re being used in other industries, but whether we have NIH syndrome (“not invented here”) or something similar, we don’t take advantage of a lot of the work that’s already been done by the experts. We’re really in our infancy when it comes to our approach on how to improve health care.
When I trained in Lean and Six Sigma, I realized, “Oh my gosh, there is this incredible tool set out there. How do we get it to the very busy people in healthcare who are at the tip of the spear helping patients? How do we get those tools in their hands? That would be a really powerful combination.” That’s where a lot of my work came from, in trying to solve that challenge.
When did you first notice the results of these better tools?
I remember distinctly when I was training in transplant surgery, we did a liver transplant on a patient in what is typically considered a very brief amount of time for a liver transplant.
We didn’t rush, we did everything the way we normally did it, and when we looked up at the clock at the end of the case, we said, “Oh my gosh, how long did that take? Wow, for a liver transplant, that was unusually quick.”
Liver transplants take a median of about four hours. This was more than an hour faster than what we typically see. And yes, we had done all the connections, all the anastomosis. We’d done everything we needed to do, but it was markedly faster.
I’m not chalking this up to incredible ability on my part. I was fortunate to be part of an excellent team, with an excellent lead surgeon. I was not the lead surgeon, who was incredibly talented and a large portion of why this case went so well. Still, there were many other things that had to line up.
What it made me do is think back on what lined up to produce excellence, and how is it that we can capture that lightning in a bottle every time to make each event go the best way it can.
What is the #1 takeaway from your book?
Healthcare is in transition, and that means those in healthcare need to be better than ever at promoting quality and value. Value for our patients, and quality in the outcomes we see.
These tools are useful not just to avoid defects, but how to make excellence routine.
It’s time to use these advanced quality tools that already exist, because waste is less tolerated than ever with our current system. The book gives specific examples about what those tools are, how we’ve applied them before in different systems I’ve worked in, and what we’ve seen in doing that.
There’s now less margin for waste. Hospitals at the macro level and healthcare systems are now being reimbursed, paid for the work they do differently.
What are some of the tools?
Six sigma is just a name for a tool set that Motorola and other companies brought together. Basically, they’re well-known statistical tools that are strung together in a certain way, to help us get a deeper and richer understanding of what we need to do to improve a system, and to let us know when we’re doing better after we’ve made changes.
It takes it from the realm of, very focused on individuals and very rudimentary understanding of what makes a defect, to a much more valuable and larger understanding of how to align things so the system goes right.
The book actually goes through and references specific tools used by that system and how they’ve been applied to hospitals before, so that people understand that we can use them and they work to great effect for healthcare systems.
Can you give an example of using a specific tool?
We had a center that was a trauma center and it had a hard time having enough patients come to it. One of the interesting things that started to happen as it improved and got busier is it got so busy so fast that we weren’t able to help all the patients we wanted to. We had to say, “We can’t accept those patients because we’re filled up.”
We started to look at a very complex problem that many hospitals have, which involves what’s called “throughput” — outpatients come in the front door until they eventually exit the hospital doing better, and they’re ready to go home. These are super complex, because everybody has an opinion on what’s doing it.
We got a group together to look at how we could improve this to allow us to take care of more patients when they came in the front door. One of the tools we used is called a “fishbone diagram.”
In our case, the problem we had was called “time on diversion,” when we had to divert patients away. We all sat around and we thought about as a group with different members, some from the emergency department, some from the hospital floors.
We had opinions about which of the categories was making us have this diversion time, and this difficulty getting patients through the hospital. We each saw just one small part of this picture, but this fish bone diagram helped us see what we all thought.
Next, we collected data on each element of our opinion. We used one of the tools called a “multiple regression” to figure out which thing did impact significantly, this amount of time we had in the hospital, this time on diversion where we couldn’t take new patients.
What were the benefits of using those tools?
We got out of the realm of our opinion by using these tools. It turns out, some of the elements we thought were important — like which ED doctor was on that day — we did not predict at all. It was great because it took some of our colleagues out of the very personal focus.
It showed us that didn’t really predict how long we were going to be on diversion, but what did in our case was how many beds we had staffed in our intensive care unit. Meaning, how many were open and how many had nurses to take care of patients for those beds.
We discovered that was very correlated, that was associated with how long and whether we were on diversion. We fixed that.
We opened more ICU beds, we added staff so that we could cover the beds. And suddenly, we did not have diversion anymore until the time that I left the hospital, which was more than a year later.
What would happen if more healthcare professionals used these tools?
The patients do better. We get higher quality care for patients and we get more valuable care, because it turns out that when you don’t have as many problems or defects, you don’t waste as many resources. Sometimes that’s money, but sometimes it’s other resources like equipment.
We don’t see as much waste, and we see better outcomes.
“You find out after a while that the least expensive care is the highest quality care. It really works for everybody involved.”
Providing better quality really decreases waste and expenditure. It’s great for everybody.
Have your colleagues read Volume to Value?
I’m proud to say that I know of at least one colleague who uses the tools listed in the book. I’ve just been so happy to hear that in her practice at her hospital — and even on her approach on a day-to-day basis — she’s been able to make meaningful improvements in her practice and for her patients. She’s seen really great results by what she describes, and that’s very fulfilling.
There are so many things that we do as physicians. We spend a lot of our time charting, writing things down, and less with patients. She’s been able to decrease the amount of time that she spends charting on patients, writing everything up with no change in the quality of what she records. That’s freed her up to spend more time with patients, which is awesome.
I’m very fortunate and proud to help the patient, who comes in and who’s injured, and we get to operate on them or fix them up otherwise, and they feel better. That’s very fulfilling. And getting this information out there to help improve care for patients is also incredibly fulfilling.
It’s helped her when she reviews cases for her subspecialty, because it brings a different way of looking at the cases beyond just the people involved to the system elements. The things that lineup to make a defect along these sort of six known categories. In terms of tangible results, she’s been able to improve the time spent with patients, adding value for the patient, and decreased wasted time and motion on her rounds. That’s been great.
What’s the rest of the year look like for you?
I’m an invited speaker for a couple of conferences throughout the country. I usually will go to speak at Minitab, although I am not sponsored by them or anything like that. They’re a really well-known company that does the program a lot of us use, and they connected to me more than two years ago and usually invite me to speak.
If you were going to write a follow-up book, what would it be?
We have been in a lot of uncertainty for healthcare for a while, But we had the sense that we knew the direction of the Department of Health and Human Services was going in, because we knew how they were changing reimbursement. But now, after the presidential election and with Tom Price heading up Health and Human Services, we’re kind of in a holding pattern.
Everyone still thinks everyone is going in the value based reimbursement direction. Even if they are not going in that direction, it’s still the right thing to do for patients. To try and provide the highest quality and most valuable care we can.
If I were going to write a follow-up book about how quality and reimbursement are tied and what tools we can use, I’d wait and see until after the Trump and Tom Price bill gets through the senate.
The other side I have seen in healthcare is how culture impacts everything we do. You and I have talked today about the tools to improve quality, but believe it or not, even though we know these exist and we know they work well, sometimes the culture of the hospital is not palatable for different reasons. So I would write a follow on book about techniques to align culture.