Jess Jacobs, former Director of Innovation at Aetna, had two rare diseases. A Green Belt Six Sigma, Jacobs calculated the efficiency of her health care over the course of a year — for her, time saved equates to quality — and saw poor results. A 12-hour wait in the emergency room had only 7% process cycle efficiency. Out of 56 outpatient visits (only 29% of which were useful), 20 emergency room visits, and 54 inpatient days across nine hospital admissions, only 0.08% of that time was actually spent treating her conditions.
“In health care, we deliver very little quality when defined by a metric that matters most to patients: patient time,” says Nirav Shah, Senior Vice President and Chief Operating Officer of Clinical Operations for Kaiser Permanente Southern California. “If we reframe thinking about quality and measuring quality, it forces us to become very patient centered, and even a little uncomfortable as doctors, as we come up with innovative solutions to some of the most complex problems.”
For example, the average hospital stay for a hip replacement is three to four days, according to Shah. But what if we could lower that average to zero?
A number of hip replacement patients at Kaiser Permanente get to go home on the same day of their surgery. Shah explains the steps that are taken by all team members to ensure safe, high-quality care:
- Pre-operation: A nurse visits the patient at home to explain what to expect and to remove postoperative fall hazards, such as rugs. A pharmacist visits to explain medication changes. And a correctly sized walker or cane is delivered to the home.
- During surgery: The hip replacement surgery is the first case of the morning. The orthopedic surgeon chooses from three devices: small, medium, or large. “The minor differences of one surgeon’s preferences to the next are subsumed to the greater good of standardized preference cards, standard workflows, improved safety of nurses having to learn fewer devices, and decreased infection rates,” says Shah. After recovering from the operation, the patient goes home.
- Post-operation, surgery day: Once the patient is home, her first physical therapy appointment happens there. In the evening, the surgeon calls the patient by phone to ask how she is doing.
- Subsequent post-op: Physical therapy takes place in the patient’s home the next morning, followed by a nurse visit, also at home. A physician reviews their notes in the electronic health record midday. A second home physician therapy session occurs in the afternoon. The next morning, the surgeon conducts an outpatient appointment.
“How much quality time do we give back to Mrs. Jones, who can recover in the comfort of her own home, surrounded by her family, away from the constant din of the hospital?” asks Shah.
The most important factor in achieving these patient-centered outcomes is standardization, Shah says. Another “important but unheralded” factor is customization. “The mistake that we make over and over in medicine is that we usually start with customization. Every patient is unique. Every patient has nuances that are meaningful. Yes, that’s true. But let’s start first with what’s common, not with what’s different,” he says. “Templates matter. Algorithms matter. They raise the bar, and not actually reduced to the least common denominator.” After adding customization to that standardization, never lose sight of the collective needs of the patient, her family, and the local care team, advises Shah, because “with every optimization of a system somewhere you run the risk of de-optimizing the system for someone else.”
Returning to the story of Jacobs, Shah notes that she spent nearly two months of her life waiting, instead of healing. “Maybe health systems should be rated on how much time they give back to patients like Jess, how many ‘days’ at home per year they achieve for her,” says Shah. “A tragic footnote about Jess: she died in August, at the age of 29. She has no more time.”
“I hope that you believe, as I do, that speed is quality, that standardization is innovation, which allows for mass customization, and that we need to give patients more of what they want and need from us — time.”
From the NEJM Catalyst event Hardwiring Patient Engagement to Deliver Better Health at Kaiser Permanente Southern California, April 13, 2017.