Person, Process, Product

August 17, 2010

Person, Process, Product

Once a committee has decided on a plan of action, the next step is implementation — the rate-limiting factor that must occur after equipment or process has been approved! In my opinion, this step is the hardest to execute. And that’s why systems look for champions (persons) to serve as catalysts to help “get things going.”

Therefore, provider “buy in” must occur early. The only way for that to occur is to use physician-driven committees. The Physician Drivers should not be chosen based on seniority, but on an established record of excellence to get a particular job done. These people must have education in the field, be willing to learn new things, have up to date credentials, and must be great communicators to successfully get the word out.

I have learned that physicians with education in a field need to have a role in advancing new technologies or processes in the hospital system. That said, control of conflict of interest with appropriate checks and balances needs to occur so that stewardship takes place. The goal is high quality, low cost, and an exceptional patient experience. The sum of these 3 parts is VALUE!

Let me clarify. If there is an expensive product that I want to purchase because it is cool and will help give value to patients, there needs to be someone there to “check” my thinking and provide balance, so that my conflict of interest (wanting the product) doesn’t get in the way of doing what is best for the system and the patient. Maybe, for example, cardiology does it better than nephrology, so I’ll let them do it because its the right thing to do.

Remember, its now about the 3 P’s (in addition to the 3 A’s*): Person, Process, and Product.

  1. Person: who is the best person or the most appropriate speciality for the job?
  2. Process: what is the best process for the job? Should we use lean or Six Sigma?
  3. Product: what is the best product defined as the one that is the most cost effective, the best manufactured, and the one that gets the job done. There should be high sensitivity, specificity, positive predictive value, and negative predictive value associated with any diagnostic product. Therapeutic machines should have outcomes data that prove efficacy to provide patient value.

Many hospitals have interest in creating a “virtual hospital.” A virtual hospital is a system which has the ability to utilize “cutting edge” technology through top-notch manufacturing to detect disease onset earlier so that disease can be prevented. Moreover, a good virtual hospital should also have the ability to monitor hospital ward patients (the lowest level of care in the hospital) in real time, avoiding catastrophic events.

Please don’t misunderstand. You CAN have it both ways. The only time a person, product, or process should replace what is currently in practice is when the math suggests that quality will improve while cost will ultimately decrease. Did you know that Toyota lost money on every Prius it sold initially? Now, they make the premier product for a profit and own the market. So the product may initially cost money, but if the system benefits in a positive way, then the money is well spent.

I’ll clarify with an example:  I had the honor to work with the Alegent Hypothermia Group to develop a 5-hospital, system-wide protocol to cool out-of-hospital cardiac arrest patients — therapeutic hypothermia after cardiac arrest. The evidence in favor of using hypothermia after cardiac arrest is phenomenal: for every 7 patients cooled, one life is saved (assuming an absolute risk reduction of 14%). Today’s numbers, using Dr. Kern’s protocol (the one in use at Alegent Health), are even more impressive. Please note: Dr Karl Kern from the University of Arizona will be one of the keynote speakers at the Annual Cardiology Update on September 24th at the Omaha Marriott Regency.

My understanding is that CHI Health is the first and only hospital system in the region to offer the service at more than one hospital. During the discussions to bring the concept to fruition, we noted that infection during this process is a real concern. If a person is cold, how can we detect if there is an infection? In other words, how does fever present itself in a patient we are trying to cool? People have used “time to cooling” or “difficulty maintaining cooling” as a marker for infection. My opinion is we currently have no good options.

There is a product for continuous temperature monitoring (braintunnelgenix.com) not yet available in the United States. Their system uses continuous non-invasive temperature monitoring:

“The Brain Temperature Tunnel (BTT™) is a direct and undisturbed connection between the thermal storage area in the brain and the surface of the skin at the inner corner of the eye.

This “tunnel of light” enables humanity — for the first time in history — to have noninvasive, continuous temperature measurement.”

Perhaps early knowledge of an increase in temperature will allow for earlier detection and management of infection in therapeutic hypothermia. The early warning may indicate the need for broader spectrum antibiotics in this setting.

So although the theory is good, the company needs to prove to the hospital system that the temperature sensor is better than what we have now in terms of length of stay, cost, and patient outcome — survival.

Also, we have to watch out for lead-time bias. Wiki defines lead-time bias as the bias that occurs when two tests for a disease are compared, and one test (the new, experimental one) diagnoses the disease earlier, but there is no effect on the outcome of the disease—it may appear that the test prolongs survival, when in fact it only results in earlier diagnosis when compared to traditional methods. The time of death in lead time bias is the same. This concept is an important factor when evaluating the effectiveness of a specific test.

Here’s the point: the product may be worth adopting in practice if there is a true benefit with earlier detection. However, once disease is detected by the product, there must be a system in place for the physician to act on the data. Because if a tree falls in the forest, it only makes a sound if someone is there to hear it.

In conclusion, I believe in using technology appropriately. In order to be adopted, the plan of action that is developed must be shown to be “better” than what is currently used. We need to consider using real measures of outcomes. The right people should perform the studies, using the right products and processes. In order to survive the current health care environment, our goal should be to improve quality while lowering costs thereby providing value to our patients.

*The 3 A’s: Availability, Affability, Ability

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