One summer, during my vacation, I read the book: ‘Doctor is Sick’ by Gonny ten Haaft, a Dutch healthcare journalist. In it, Gonny reports on conversations she had with healthcare professionals and managers, who themselves ended up in their hospital as patients. The book inspired me to take notes of the images, conclusions and ideas it evoked, formulated from my perspective as a “lean thinker”.

A while ago, I came across these notes again and in consultation with Gonny, I thought of turning them into an “article”. It is not a book review, but the recording of my thoughts, so that they can then in turn inspire better patient care. Just as Gonny intended.

The current situation: do we still see it?

For me, the book makes it crystal clear what is going on in our hospitals and what should be done better. Although anecdotal, it exposes quite a few problems, which for me make it clear that the current healthcare system is not good enough. I encourage everyone to read the book (only in Dutch unfortunately) as well or even “better”, engage as a patient in their own hospital. It will open your eyes to how the system is working now and where it could (or actually should!) be made better.

The Ideal: world-class health care

Lean Thinkers like me, strive for the ideal, for world-class health care for all patients. With the phrase world-class health care, many immediately think of international comparisons. And yes, then we appear to be world-class in the Netherlands.

However, if you read Gonny’s book (or visit a hospital yourself), you don’t get that feeling. Why is that? In my opinion, patients do not want care that is better than that in France, Africa or Singapore. They want ideal care (although they often settle for less). And we are a long way from that, for a variety of reasons.

So, what is world-class health care?

My definition (was): World Class Health Care is a system, in which people (improve) themselves every day in order to deliver “Safely and with compassion, the right care, at the right time, to the right patient, without waste or struggle.”

The book made me aware that in addition the patient needs to have clarity at every moment of the process, about what is exactly (not) happening/not going to happen when, so that feelings of uncertainty, loneliness and anxiety are minimized. You need to provide the right information at the right time, for the patient to feel the better. High reliable and predictable health care is of the essence to patients.

The barriers and what can we do to remove them

Gonny’s book gives insight into the various barriers that exist now – in people’s minds – in hospitals If we want to improve care we will have to look for the barriers and find out their root causes. Once we know the real causes then it is much easier to devise and implement effective measures. I have listed the measures that came to mind while reading without trying to be exhaustive or pretend to know all the answers.

No time

It seems that healthcare providers are very busy, so the patient does not always receive adequate attention and care. The question this raises is: “so what do all the caregivers do when they are not with patients?” Possible answers: walking, searching, being with colleagues in the coffee room or nurses’ station, administration, recording, correcting errors, collecting materials, etc. And that in turn begs the question: why do they do all that? And if it is necessary, why do they do it?

Lack of clarity in the communication of health care providers

Patients perceive ambiguity in communication as a major problem. And rightly so! Ambiguity is at the source of many of the mistake in health care. The book recommends improving communication by healthcare providers. Have them tell patients much more specifically and unambiguously what to expect. This is a solution at the level of the individual caregiver and is certainly going to help. However, this requires a lot of training, and thus time and attention. In addition, human communication is a very ineffective tool if we want processes to be predictable and unambiguous. It is almost impossible to get the pictures in our heads, through words, to the same picture in someone else’s head.

To avoid communication problems, methods such as visual management have been developed in industry. This method ensures that, without consultation, what is (in)correct can be seen at a glance. About alternative standardization methods, which ensure error-free or error-tolerant processes, I read nothing in the book. This raises the question for me: are these methods known in hospitals?

Actual patient condition not (fully) known and/or recognized

In addition to the lack of clarity discussed above, not all healthcare providers seem to have compassion for and with (the situation of) the patient. This leads to the fact that it is not always known, and/or recognized, what is going on with the patient at that moment and how he/she is feeling, while this is very important for the patient. Compassion and empathy should be core competencies for health care providers and, after safety, should be at the top of health care providers’ priority list (see also Fred Lee’s book, “If Disney Ran Your Hospital”, Lee 2004).

Management system is missing

The stories in Gonny’s book raise a lot of questions about how work is managed and employees are led. Questions that came to my mind:

– what exactly is the role of management?

– when are they doing their jobs correctly?

– how is the team performing?

– how did the patient experience the care and cooperation?

These questions remain unanswered in many hospitals. And where they do have answers, they take way to long to get to the right person, or they are communicated not at all. This makes a process of daily improvement and learning almost impossible.

Efficiency is the goal?

The book conjures up an image of healthcare organizations steering, probably unconsciously, toward provider efficiency, making sure they spend as little time per patient as possible.

The order of priority for decision making seems to be:

1. efficiency
2. treatment and care tasks
3. safety
4. personal needs of patients

This is almost at odds with the order that Fred Lee provides based on the Disney philosophy (Lee, 2004).

Medical technology makes care more expensive and less patient-centered?!

In many articles and similarly in Gonny’s book, it is argued that developments in medical technology are making health care increasingly more expensive and less patient-centered. This is remarkable and in many other sectors unthinkable. Many companies would go out of business if they used “higher cost” and “less customer-centric” as design criteria for their technology.

“You get the machines, you ask for!”

– Mike Herscher, former Lean director, Boeing

Registration systems miss the mark

There are a variety of registration systems, often imposed by third parties, for health care providers, to hold them accountable. Why is this important? The off book of Gonny shows that despite these systems things are still going wrong or even more so. There seems to be no relationship between registration systems and the improvement of health care. Where that relationship does exist, there is a long lead time between the occurrence of the problem and the action taken.

The registration systems would improve greatly when the data would be fed back to and discussed with the team. It can  also be used as management information. However, when the manager wants to know how the team is doing, it is best to do so daily, on the shop floor, where performance is being delivered, based on their own observations. This leads to ownership of performance and the ability to take action when problems are still small.

“We are not a factory!” Or are we?

I am told by many a healthcare provider, in response to my ideas of applying “Toyota principles” in the hospital, “we’re not a ….. factory, are we?” And if you take that literally, of course that is true. However, when I see (and read in the book) how hospitals are run, it conjures up a very different picture. It seems almost literally to be about production management.  Care delivery, treatments and also patients are even referred to as “production”.

Van Boheemen, Anesthesiologist, says in the book, “It was only when I was a patient myself that I realized that hospital discussions are only about money, staff, bed availability and operation times. It’s never about quality of care, about how providers can provide better care for patients.'” This looks suspiciously like running a factory, but according to the principles of years past: Most factories haven’t been doing it that way for years! It creates a huge “disconnect” between management and healthcare professionals, let alone patients. I am very curious to know how the managers and executives interviewed experienced this, as patients.

I myself am convinced that Van Boheemen had run into one of the key problems that stand in the way of world-class health care. It is worrisome that this became apparent to him by chance and in the position of patient.

The PPPP circle

Much attention is paid to new plans, ideas, agreements and/or protocols instead of to the actual implementation, testing, adjustment and standardization of improvements. Partly because of this, improvements take a long time or are not implemented at all. A typical example can be found in the book (under endnote 38). The IGZ (The Inspectorate for Health Care, in The Netherlands) identifies a problem in 2009: fragmentation of cancer care. And it also already has the(?) solution: one person as director of the entire treatment process. Subsequently, [IGZ] then “responded with delight” when associations publish in 2010 that they will introduce a guideline in 2013(!). A lead time of 4 years for addressing a problem, leaving the question of why this is the solution and why it has to take so long. Surely you can just give clarity? Or perhaps this solution was symptom control?

How is it that especially in the medical world, problems are not solved methodically?  The PDCA – Plan, Do, Check, Act – improvement circle; also called the Deming circle, has degenerated into the PPPP circle: reports, guidelines and regulations, often based on assumed problems, which should then be implemented by others. After which we jump to the next problem.

Training (method) incorrect

Each of the interviewees indicates that there is insufficient training in the skills of dealing with patients and, for example, managing the human dimensions of health care. As far as they are concerned, this should already be in basic training. Their further advice is “Classes, courses and workshops should help ensure that …….”

Apparently, the behavioral and human side of delivering quality is understudied in the training of healthcare professionals, while it is very important for patients. What is further striking is that there is a belief that “traditional” methods of training – incidental, classroom – are the right way to make this better.

In my experience, improvement is easiest done in small steps. A key change that is needed is the communication with the patient and the compassion that healthcare professionals have for patients and their particular situation. Asking a question like “can I do anything else for you?” or leaving your patient with a statement like “I’ll be back with you in 30 minutes” takes as much time as keeping your mouth shut or saying ” I’ll get back to you later”, which is rude or vague. Go for service and clarity.

Meanwhile, several studies have shown and it is my personal experience that, to learn new routines, daily practice and coaching are needed. This means that in addition to healthcare professionals, their leaders should also be trained, so they can become the coaches. They should also practice daily and receive feedback. Furthermore, continuous learning will require continuous monitoring of the quality of patient care delivered. This also means new routines for managers, which should be anchored in the currently missing management system.

The healthcare professional must “simply” change their behavior. Silos lead the way.

Van Dijk, Nurse, suggests that healthcare professionals need to make different choices (more in favor of the patient) and that she does not understand how it can be that that does not happen. The solution she gives for this is for colleagues from the same discipline to hold each other accountable. Basic care needs to be top priority again. One way Van Dijk is trying to do this is through participation in a Nursing Convent. What role is reserved for managers in here ideas is not made clear.

Her assumptions seem to be:

1. If everyone, individually, in each discipline does their job well, the whole performs well
2. Behavior is a function of the individual, so you can “just” change that yourself
3. Quality improvement goes through one’s discipline: nurses talk to nurses about improvement; doctors to doctors; etc.
4. Healthcare professionals are individually responsible for how work is done

Dr. W. Edwards Deming states that quality is a function of the system (not the individual). Therefore, if we want to deliver the right quality, we must look primarily at what the patient needs and what process is required to do so. This process should then guide how we organize the work and the collaboration (as opposed to taking the the organizational structure as the deciding factor). We need process teams, in which doctors, nurses, support services, administrative staff, etc. work together and are responsible for the outcomes, together. Such a process team should be led by a process owner.

Making choices for – instead of with and/or by – the patient

In the AVL (Anthony van Leeuwenhoek, cancer center), the waiting rooms are crowded. They assume that there is little that can be done about this “….because it is caused by external factors [ like a growing number of patients ]”. This raises the question in my mind, “if you can’t handle the patients, what is the reason you call them up?”. Then, later in their story, it turns out that the crowded waiting rooms are also the reason why people are not assigned a regular doctor [while according to Van Boheemen, the conversation runs much better when the doctor knows him].

AVL determines for the patient that short waiting time is more important than choice of doctor [while they know that this is certainly not true for every patient]. They also state that a regular doctor for each patient is not feasible because of doctors’ schedules (!).

All this teaches me that:

1. the process is organized from the perspective of doctors and the hospital instead of from the patient perspective
2. The AVL thinks it is “either / or” instead of “and / and” when making choices and solving problems.
3. They think they can’t change anything.
4. the problems created by the current condition (waiting, lack of clarity, not having the best suited doctor,…) all end up with the patients.

These are all detrimental to the quality of care and the patient experience. Don’t patients already have enough problems?After all, why else would they come to the hospital? In my opinion, patients should actually expect and get more choice and service than in other sectors, but this is clearly not the case.

Who owns these problems?

From personal experience, I can tell you that the above are not incidences. They represent the current condition of many healthcare processes. These can have horrible consequences, so you might even think: “Who’s to blame?”. But will it help if we know “who done it?”

I think the first thing we need to do is bring problem awareness to those who own the processes that are failing. In my opinion this should be one of the main responsibilities of managers, but this is not always the case, as Van Boheemen experienced in his hospital, and I did in mine.

What is the quality of your processes and who owns it?

Arnout

PS all of the issues in this article are far more elaborately discussed – through my Lean lenses – in my book “Lean Thinking in Health Care. Safe, compassionate, zero waste, no struggle”

References:

Haaft, G, Dokter is ziek, als patiënt zie je hoe zorg beter kan. AtlasContact, NL (2010).

Lee, F., If Disney Ran Your Hospital. 9 1/2 Things You Would Do Differently. Second River Healthcare, USA (2004).

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