Michael Davies

"Can You Use Your Innovations to Help Other Staff?"

Thursday, 8/23/07

Davies: Wow. I don't know how I can top all of that glitz that we had
this morning. Thank you for coming and staying for the last day. So have
you had a good time? When I came for this thing, if you guys are like
me, or maybe us guys are like this, I don't know, does your wife look
over what you put in your suitcase? Yeah, she said, "Mike, you're going
to talk to 1500 people, you need to wear your suit." So I said, "Jeez,
they're a little more casual, these are like regular people, Sue." She
said, "No, no, you need to wear your suit." But I see that I can take my
suit off. So Becky, I thought I'd do this for you. Alright. I have not
been able to come to the VeHU conference for the last couple of years,
and I have to say that my interest has really gone into how do we
improve access to care for veterans? When Becky and I ran into each
other six months ago or something we had like a two minute talk, and all
of a sudden I realized that I should really be talking to you guys about
the advanced clinic access. There's a huge innovation that can be made
when we bring together people who've not thought about the same sort of
things in the same way. So I'd really like to show you where I think the
innovation and the marriage between the electronic medical record and
what our mission is comes together today.

There's a paradox here, I think, when we talk about innovation. I don't
know about you, but when I think about innovation I think of something
big, something like that, right? I mean, we saw some of that this
morning. It's going to be a new idea that takes the place by storm. We
can't do it without equipment, without changing the code, without
rewriting software. We're waiting for something that's really going to
come along and make our lives easier, right? Isn't that the way
innovation occurs? I don't think so. It's actually more like this. We
all know what this is, right? We see it every day. It's more like
something small, something maybe that plants a seed, and the seed maybe
grows and spreads. The way innovation occurs is not from somebody out
there in space, but it's from us, who are working in the clinics and
working in our day-to-day jobs that make a discovery, that do something
different, that find a way to make it better. Just like the guy who
decided he was going to take twelve veterans to the memorial, and now
it's something big. So we do this stuff all the time because we're
scientists, right? All of us in this room are scientists, we think
scientifically, and this innovation occurs by scientific thinking. This
PDSA, plan-do-study-act, really is nothing difficult. This is the way
innovation occurs. We plan and experiment. Gee, how about doing it this
way instead of that way? And we try it out. Did it work? And then we
look and see did it work, is this really a better way or not? And if it
is a better way then we change to that way. If it's not a better way,
then we stick with the old way. How many people have done PDSA's in
here? A lot. So you guys know this stuff, right? What do you learn more
from, a PDSA that succeeds or one that fails? Fails. Absolutely. We
learn more from our failures because then we know how to do it better.
So what we're really doing here, I like this version better, the
unofficial version, we have a hunch. You know, I think this might work,
and let's test it out, let's try something different and reflect, and
see if it worked and then change and keep doing it. The paradox is that
it's really these small changes, these tiny changes that we repeat over
and over again, that all of a sudden we wake up one day and say wow,
this is an innovation, this is something special. The interesting thing
is most of us do it in isolation, so we really don't know or recognize
it as special, this is something we do every day. We do it in isolation,
and it isn't until we get together like this that we can finally see
what we do compared to somebody else that makes us wonder if this isn't
a better way, or discover a better way. This is how Toyota thinks, and
remember, Toyota is recognized for innovation. They have the Toyota
machine, which is really the people of course who work in the Toyota
factories every day, and they've made so many innovations that Toyota
now makes more money in one year than all three major American car
companies combined. The way they do it is recognizing the small things.
They break a process down into the smallest possible steps. They
recognize that it isn't somebody out there that does it, it's somebody
in here. People who do the work must transform the work, not somebody
outside the work. And they promote and encourage experimentation. Not
unlike VA CPRS VeHU has done to create the best medical record system in
the world. It's widespread experimentation by everybody that contributes
to the best car product in terms of Toyota. And then once a good thing
is found, standardization is not a bad word. Now I know there's a lot of
clinical people here. What happens when you go home and you say to the
staff, no, no, no, don't do it this way, do it this way. What happens?
Resistance? Resistance and no, I'm not doing it that way, are you
kidding, I'm doing it my way. We have to learn in healthcare, I think,
the value of standardization. We can't improve a process until first we
all do it the same way. Once we all do it the same way, then we can
improve that one way, but if we live in a world where we let a thousand
flowers bloom, how can we improve that process? We can't. First, we have
to standardize. So I have a script, if you guys want to go home and talk
about this, for you to take home, and the script is this: Feel free to
do it just this way until a proven better way is found. Once we find the
right way, everybody should do it that way. That's one of the secrets of
organizations that innovate. Experiment widely to find the best way,
then we do it the best way. Alright, so what is Mike really talking
about here? How do we think about innovations? Do we think of it from
the standpoint of the computer, or us if we're a computer person, a
clinical application coordinator, do we think of innovations from the
standpoint of the staff, the patient, the nurse, the doctor, or is it
the patient? How do we think about innovations? This is a key point
because in order to improve a process, we have to step out of our
paradigm and think about what the process looks like and feels like,
from the standpoint of the patient. So here it is, here is one way to
sort of look at this from the standpoint of the patient. Let's say the
patient comes into the clinic, the first blue box there, and checks in.
As you can see from the blue bar, there's some value that happens here
during this check-in process. They are greeted, there's demographics
that are taken, check your schedule, see if there's any lab tests you
have to go to first, and then there's what after that? Waiting.
Absolutely. Then eventually the patient goes to see the nurse. Now
there's some value created when they see the nurse. They have chronic
disease and prevention questions and issues that come up and are
discussed, and there's value created in that, a lot of value. And then
what happens after that? We wait. It's sort of like traveling by the
way, sort of like stand in line wait, value for a few seconds, then go
to the next thing. After they go from check-in to nurse, then finally
they get to the place usually that they came for, and that is to see the
doctor. That is what I call the red zone. This is where the real value
is created, because this is what they came for in the first place,
because frankly this is what we sell in healthcare. I mean it's not a
visit, but it is a what? A relationship. We sell a relationship. Now I
hate to think of us selling things, but we sort of do that, that's the
value that we create is this relationship. That relationship happens in
the red zone. That's the key most valuable part of the patient's
experience to the clinic, and nothing against nurses, nurses are
creating a huge amount of value before the red zone, and so are the
clerks. It takes a team to do this. But frankly, the doctor is the most
expensive part of this, and tat's the part we need to make sure works
well. After the red zone there's waiting, there's more value created in
a check-out process, probably more waiting and eventually they go. Now
behind, of course, each one of these value steps there are processes
represented by the blue boxes, there are blue circles here and white
circles, in fact, there's hundreds of processes that have to work well
in order for value to be created. Some of these processes might be
registration, billing, phones, authorization, scheduling, referrals,
messages, rooming, advice, teaching, order entry, care under protocol.
There's all kinds of processes. And the care that this patient
experiences can only go as fast as what? The slowest step. So if
everything speeds along but we're waiting for the imaging report, if
we're waiting for a room, if we're waiting for a code to sign onto CPRS
because we forgot it, then everything stops until that thing is
satisfied. So the work, the flow, can only go as fast as the slowest
step. It can only go as fast as the doctor can do view alerts, as the
team can communicate results, as the team can community notes, as the
doctor can enter into the progress notes, as the doctor can order a new
medication going through the dialog boxes, and on and on and on. This is
the fodder of innovation. This is our day-to-day work. So we could look
and dissect, like Toyota does. Behind each one of these value steps
there are hundreds of processes, and each one of these processes is made
up of steps. You can blow those up and expand them, and we can draw a
picture of them. Here's a picture of the specialist referral process. It
might be like this, the physician orders a consult, the clerk makes the
appointment and gives direction to the patient. So three steps, two
tasks, they take time, we could dissect it out and figure out how this
works. And as we make small changes in these things, everything goes
faster, smoother, better. Wow, innovation, cool. And in this world,
details matter, and I love this quote. "Just ask anyone who spent a
night in a tent with a mosquito." Right? Details matter. Now I want to
switch gears for a second, and let's relate this to everyday life. I
have with me a gracious volunteer. Let's give a round of applause to
Karen Robinson, Chief of Staff at Fargo. Okay Karen, would you hold up
the item on this table? Now Karen is sort of a farm girl from North
Dakota, and Karen is going to show us how she folds a t-shirt. Alright.
She lays it down face-down, she folds in a side, she folds in the other
side, she folds it up a little bit, folds it down. Okay, now would you
hold it up for people to see? Alright, thanks. You can go ahead and sit
down. Okay, how long do you think that took her? Eight seconds,
something like that. I had another volunteer in case you couldn't see
that from the back, here's my daughter, and she actually happened to do
it the same way that Karen did it, I guess the Dakota people are about
the same here. Lay the shirt down, fold in the side, this is the way
Becky did it too, fold in the other side, and then fold the bottom
halfway up, and then fold it like that, and now she's holding it up for
you. Now Becky wanted you to know how she sometimes folds a t-shirt. And
I can attest to this, having seen Becky's room. Alright, there's then a
process, and we can draw a picture of it, like a flow map, and here's
exactly the steps that Karen and Becky both happened to take. Now I want
to show you a little innovation. So if we could please run the video, I
want to show you how they fold them in Japan. (video plays) Pretty cool,
huh? You want to see it again? (video plays) Remember that when you go
home, it takes a little practice. Here's how they do it in Japan. Lay
the shirt on the table front side up, put your hands on the shirt, fold
it and lay it down. There's actually three steps. Becky and I timed this
this last weekend actually. The old process takes six steps, the new
process is three. The old process takes eight seconds, the new, four.
Now if Becky, Becky told me she washes about ten t-shirts every two
weeks, and I wondered about that myself but that's what she said. So she
washes about 27 times a year. Now if Becky lives 90 years, the total
number of seconds that she's going to spend folding t-shirts under the
old process is almost 200,000, which is about 54 hours. If she adopted
the new process she could do it in her life in 27 hours, thereby having
27 hours to spend doing other fun things. This is how innovations work.
Now isn't that cool? That's an innovation in everyday life. Now I
started to tell you about the red zone. Let's look inside the red zone.
When I do ACA stuff, in a lot of places the number one complaint I hear
is that the computer adds a burden to us, it's hard to do a visit with
the computer because there are so many things go do. And I said to
myself, self, look at the people here that can do innovations. I know we
can do this better. The computer is designed to help, not hinder. We can
do this better. In order to do it better we have to start thinking
differently, I think. We need to remember that what we sell is a
relationship, it sometimes happen in a visit, sometimes not. The red
zone is where value happens. That's what patients come for. And the
number of red zones the doctor can produce in a day, in a clinic visit,
in a session, is really the determination of our productivity. And the
effectiveness of the red zones determine quality. In a healthy clinic
the red zone should be the constraint. Now in perfect flow, what we have
is the doctor going from one patient to another to another. Red zone,
red zone, red zone. There's nurse work in front of it, there's pre-work,
and then there's post-work for the patient. So the patient comes in,
there's this green pre-work, red zone, post. Pre-work, red zone, post.
Now what's the flow like for the doctor here? This is the flow, it kind
of goes from one thing to another if things are working perfectly. If
things are working perfectly we can do one, two, three, four, five, six,
seven, in this example eight red zones. What's the flow like for the
nurse? Interestingly, first patient comes in, pre-work. Then second
patient, pre-work. Now what happens at the third patient? We might have
some check out stuff from the first patient in addition to the pre-work
stuff for the third patient. So there is twice as much work there for
the nurse? Why is the middle of the session busy? There's check-in and
check-out at the same time. The nurses are very busy then and so are the
clerks, so the middle of the session is all of this double work. Finally
we get to the end of the session, check out, check out. That's perfect
flow. Now what really happens? What really happens is patient comes in
late, actually more likely the doctor is late, I'm a doctor so I can say
this. And I've done lots of querying of groups, doctors are often late.
Let's just do a thought experiment. If there's 220 work days in a year,
if we do sessions in the morning and afternoon there's 440 sessions. If
we're 15 minutes late every day for our clinic session, we've just
wasted 440 visits for the year. That's huge capacity. So first thing is,
of course, we got to be on time. Second thing is we got to look at those
red zones, and look at the teamwork that happens between the nurse and
the doctor and the clerk in the clinic. And, as you can see, if we have
variations in the red zone, if the first three vary and the next ones
are perfectly on time, now in the exact same amount of time we can
produce one, two, three, four, five, six, in this case seven red zones.
Alright. Does this matter? If there are six slots per half day sessions,
then we produce or we supply, we have in the VA with one doc, almost
2,600 red zones per year, that's our supply for clinic. If we do eight
we can improve our capacity to almost 3,500. If we do ten we can improve
our capacity to almost 4,300 in a typical 1.0 FTE that works seven
sessions per week and 220 days per year, which is about it. That's a
lot. And what happens inside this red zone is often, for many of us
who've never been in there, a black box. But it's so important. Alright,
here's what happens to me. I'm going to bare my soul and confess to you
guys. Here's what happens to me inside the red zone. Now I'm a part-time
provider, so I don't know all these drugs perfectly, my mind doesn't
work quite as fast as when I'm doing it every day all the time for this
stuff. I go into the clinic, I see that a patient has a rash, they need
a steroid, and my first question is which one do we have on formulary?
So then I trot out of the office and go stand in line to get to the
pharmacist, who happens to be in our clinic, which is a wonderful thing.
I talk to the pharmacy about what we have on formulary. Then I determine
which drug it is, go back inside the clinic, there's been a major
interruption in the red zone, big sin right there, right? Then enter the
med tab, search for the drug, select the drug, fill in the dialog box,
and complete the order. That's sort of it. That's one of the things that
happens inside the red zone. And this, thanks to John Reefenburger who
helped me with this, is what the dialog box looks like. You know this,
right? Choose a new medication, type in the name, then click on the
appropriate drug, and then over here fill in all these little things,
and then when you get right here what happens? What happens to me is we
have a major delay because the patient can't decide if they want it
mailed or they want to pick it up at the window. This is what happens.
Then click on accept order and it's done. So here's the process from
decide to accept. And this is excluding the standing in line at the
pharmacy, this is the process from decide to accept. Click on the med
tab, click action, new med, type glucon, click dosage, type bid, type
prn, type 30, type 60, type 2, type 0-16 keystrokes of comments, select
pick-up, which is a delay, patient instructions, and then finally
accept. Oh my goodness. That is a lot of work for one new med. Now,
that's in the best case scenario. There's some hang-ups here. What if
you're doing this over the phone? Now you got to stop and select a
location, at least I do. That's 13 keystrokes. What if you don't know
the formulary? Now you got to find the formulary on-line or talk to
somebody, or make a phone call. What if you don't know the quantity,
like a lot of these creams are? That's a delay. What if we have to
negotiate pick-up of meds, missed fields, minimum of four keystrokes
there, arrangement of the keystroke and mouse, use of the tab key, the
keyboard skill level. I have doctors in our place that do this. Speed of
the network or computer. How much time do we spend watching that little
hourglass? Or the speed of the order checks? So in the best case
scenario, and John time me on this, decide to accept is twelve steps,
somewhere between 27 and 44 keystrokes, and 55 seconds, could be more
than 5 minutes if there's hang-ups. One new med inside the red zone.
That's the worst case scenario. Here's the best case scenario. This was,
I think, an innovation. I determine a need for a topical steroid, wonder
which one. Select a category on the computer that Dr. John Kenect in Hot
Springs championed, which is to select common drugs in a categorized
fashion. Determine the drug, finish filling in the dialog box, and
complete the order. Let me show you how it works. Under the orders tab,
outpatient meds categorized. You choose that and then you see all these
meds categorized. This is a godsend for a primary care doc that's
part-time, by the way. Oh, derm agents, that's what I want. Let's see,
here's the topical steroids arranged from low to medium to high potency.
Here's what we have on task. Yep, that will work. Let's do Flucon, so
you do that and the dialog box has already been pre filled out for me,
so I don't have to fill in all those things, or at least most of them
unless you want to change something. Talk to the patient about whether
they're going to pick it up or mail it. Now here's the process from
decide to accept. Decide, click the orders tab, click meds, click
outpatient meds, click derm, click Flucon, accept. Wow. Is this an
innovation? Maybe you guys do it better, but I don't know, for me this
was a huge discovery. This was a great innovation. In fact, John timed
me on this, it took five steps, 6 to 23 keystrokes, and in three trials
here an average of 26 seconds to do it this way. Alright, now let's
compare these. The old process took 14 steps, the new, 7. The old
process took 27 keystroke, the new 6. The old process took one minute,
the new one a half a minute. What should we do? If, and I did a little
thought experiment and I took some editorial liberties here, and I know
that we have in VA at least a million visits a day, or about a million
visits a day. I'm just going to say that every one of those visits one
new medication is ordered, and I know that's not true, but just play
along with me here a little bit. If we did the old process, for every
one of those things it would take a million minutes to do it. The new
process, a half a million minutes. The old process would take, for a
year, if this happened 220 days a year, the old process would take a
total of 220 million minutes, and the new one 110 million minute. Now if
we looked at the salary costs per day of the doctor inside the red zone,
which is the most expensive thing in the clinic, so we want to keep that
moving and use it well. The salary cost has a difference of about
\$721,000 worth of time that we're paying people to do those clicks, per
day. If you looked at it per year, there's a difference of \$160 million
in this one process. Now if we translated that into visit time,
translated that half a minute that we would save by doing it a better
way, a new way, a shorter way, we could gain in the VA at 30 minutes a
visit, 16,000, almost 17,000 visit capacity time in the VA. This one
thing. Which is why I say a small thing makes a big difference. And then
if you look at the frustration factor \-- priceless. So that's why I say
innovation is not out there, it's in here. And we've got to get it in
here more. And I think we have to standardize it. So our challenge to
you. Pick a process that bugs you. You've all heard the stories, you
know it better than I do. Pick a process that bugs you. Get somebody
that's doing this process every single day involved in it. Set an aim.
An aim focused around delay, keystrokes, seconds, time, it matters,
steps matter, draw a picture of it. Look at a measure of timeliness and
look at reliability of the measure, and keep in mind the quality of this
over time. Do we do a quality job with the new process? And then look at
tests of change. PDSA, or I like it better, hunch-test-reflect-change.
Follow your hunches here. What should we pick? When we come back next
year we would like to see tons of this stuff, and we would like you to
consider things inside the red zone. Medication ordering, progress note
documentation, chronic disease prevention and documentation that the
nurses do, there's a whole bunch of different ways we're doing this
stuff. Lab results and notification process. Oh my goodness, what a big
one that is. View alerts. I was horrified two days ago before I came
here, the primary care service line at our place figured out how much
time our doctors are spending on view alerts per week, seven and a half
hours per week. I know we're not doing this as good as we could be.
What's a better way? Computer sign on process, speed of the computer.
Some of these things we don't control, and you know what, that's okay,
because there's a million things we do control. So I say let's stop
looking out there, and let's start looking in here for these
innovations, because nothing is more important than our goal. Our
mission is to honor America's veterans by providing exceptional
healthcare that honors their health and well-being. That's our mission.
And we can do that with the day-to-day work that we do with the people
in this room. The team has to be engaged. We have to pick a process that
bugs us, teach others, develop system benchmarks, look for the best, and
see if we can beat it. And support each other as we measure and
objectively guide our improvements. This is true innovation. Thank you
very much.