Giving health care the business
Dr. Harsha Rao said he carried his idea for a team approach to diabetes treatment in his hip pocket for 25 years before discovering the Pittsburgh Regional Health Initiative's (PRHI) engineering-based, health care improvement process.
Diabetes has many symptoms and associated ailments. Treating a patient correctly requires multiple examinations and levels of interaction among clinical employees, something impossible to do within the 20 minutes or so most health insurance schemes allot for patient visits.
Also, Rao said, the physicians who see patients during that single visit don't have the training to provide other services such as nutrition and diabetes education, which a full spectrum of diabetes care requires.
Rao, now chief endocrinologist at the Department of Veterans Affairs' Pittsburgh Healthcare System, proposed creating a team that consists of a nurse educator, pharmacist, nutritionist and nurse practitioner. Along with Rao, they would manage separate stations that a patient would visit sequentially in the course of an hour.
The patient would then receive all the components of care in a single, comprehensive visit rather than have to visit separate facilities and offices over many days, with the possibility that some visits would be missed and overall care uncoordinated.
What Rao proposed was essentially a health care production line ? simple enough in concept but traditionally hard to implement in a medical setting. Physicians "are not trained to look at processes," Rao said. "We are not trained to know about efficiencies and the other things needed for this."
That's where PRHI's Perfecting Patient Care System (PPC) came in. Once Rao was introduced to it, he realized it fit his team approach to diabetes care.
PPC is based on the Toyota Production System, which the car maker uses to improve worker safety at its plants worldwide, cut waste and improve efficiencies.
It uses the just-in-time principle of manufacturing and the Japanese concept of Jidoka, in which production lines are stopped immediately when problems occur so that defects in manufacturing are not passed on and problem areas are dealt with promptly.
The concepts are universal and apply well to health care settings, said Tania Lyon, assistant director of chronic care initiatives at PRHI.
However, in the medical context, they are adjusted to apply more to people and problem solving.
One big way in which PPC goes beyond the Toyota system is in having a model to include partners in the process.
"Health care has a lot of power bases, and there is a level of organizational complexity that [a manufacturing process] doesn't have," Lyon said. "Also, such things as patient safety tends to be a lot more complex than [worker safety] at manufacturing sites."
In the case of Rao's diabetes team concept, it was essential to keep patients on track to be successful. The patients should spend no more than 15 minutes at each station, and the flow would have to be controlled so that no patient was left waiting between stations.
The goal was to identify the tasks that had to be accomplished so that the people at each station would know exactly what they had to do in each case. However, it has not been that simple, Rao said.
"We are beginning to realize that you can't predict how things will turn out and that problem solving really is something you need to do in real time," he said. "Also, there should be no finger-pointing at any one person [as the reason for a problem]. There's inevitably a tendency to do that."
What PPC brings to this is a level of exactness. Lyon's role as PPC coach for Rao's program, for example, was to observe his team in action and measure activities such as the time each patient spent at a station and then try to isolate the cause of any delays.
That data-driven approach revealed issues that were not readily apparent.
"In one case, there was a growing perception that the second station was a bottleneck, but when I finished my observations, the data didn't support that," Lyon said.
Dr. Stephen Raab started using PPC at the University of Pittsburgh Medical Center (UPMC) in 2003 to improve diagnostic testing at the center's pathology lab.
One major source of error was the quality of specimens taken during cancer biopsies. Raab used the PPC system to set up a continuous flow "learning line" in the lab that he said immediately began to solve problems by introducing tools such as checklists and set procedures for people to follow.
"We didn't know where the errors in diagnostic testing were occurring," Raab said. "The PPC looks at the whole system and attempts to change all aspects of the system at once. That was ideal for us."
Not that it was an easy thing to do, given the level of change necessary in attitudes and approach. "The process was successful, but it created a lot of stress," Raab said.
"People ended up doing things very differently from the way they had done them before," he added. "That kind of fundamental change is very threatening."
However, at least judging by his own experience, Raab said that once people start to work through the PPC system, "they don't want to go back to the old way."
That kind of demonstrable success doesn't mean that the PPC will be an easier sell to the medical field in the future.
Everyone in an institution must get on board ? higher-level executives and middle- and lower-level managers ? for the approach to work in a broader setting, Raab said.
"Outside of the pathology lab, many [at UPMC] see it as just another experiment, as a fad," he said. "Overcoming that kind of passive resistance is probably the hardest part to disseminating this more widely."
You also have to convince people steeped in the culture of the individualistic medical arts that you won't be turning their hospital into a factory, Lyon said.
It calls for people who push daily for immediate results from their efforts to accept a more painstaking approach.
It's the attention to the nagging details that provides the value of the PPC system, Rao said.
In the case of diabetic treatment, the team process catches details that inevitably fall through the cracks in a single 20-minute visit, he added.