Thursday, February 22, 2007

Cliniaal innovation - The Kaiser Way: Clinical Systems Engineering and Systems Thinking

“It’s time to stop functioning as a highly localized, unacceptably idiosyncratic cottage industry – with the exam room functioning as a medical cottage.”

George C. Halvorson, Chairman and CEO, Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, World Bank Presentation, “It’s Time to Create an Industrial Revolution in Health Care,“ September 15, 2005

After my last blog on Toyota and use of its “lean” manufacturing model at Virginia Mason Medical Center in Seattle and at Park Nicollet Clinic in Minneapolis, a friend sent me a slide presentation by George Halvorson before the World Bank in Uganda in 2005. George is CEO of Kaiser – a $30 billion integrated system headquartered in Oakland, California.

Because of space lack, I won’t go into Halvorson’s 93 slide PowerPoint in any depth. Basically, it expands the Toyota approach of system engineering and industrial engineering to the U.S. health system as a whole, a much larger scales that seen at Virginia Mason and Park Nicollet.

Now onto Halvorson’s presentation. He starts by observing that:

• Kaiser is the largest integrated health system in the Western World with 8 million members, 142,000 employees, 32 hospitals, and 12,000 salaried physicians. That was in 2005.

• He then characterizes the 2005 U.S. health system as world’s most expensive with superb technology and techniques, mediocre outcomes, and inconsistent quality.

• He goes on to describe the “Wobbly Parts of U.S, Health Care” -- the medical record, inconsistent access to current science, patient compliance, patient follow-up, and outcome tracking. He notes these are the “obvious” flaws of U.S. health care.

I like Halvorson’s use of the word “wobbly.” Wobbly means moving unsteadily from side to side, weak, and unable to keep one’s balance. This is apt. Our system is unbalanced, with too much stress on what goes on “inside” exam rooms and hospitals and not enough on what goes on “outside” – patient compliance, follow-up, and outcomes.

To solve this “outside” problem, as a solution Halvorson pushes electronic medical records – for consistency, standardization, quality tracking, and diagnostic support – and for following patients outside the exam room to see if they are complying with instructions and improving outcomes. The key to this, says Halvorson, is e-support – e-visits, e-scheduling, e-reminders, and e-care.

In Halvorson’s clear-minded world view, it logically follows that we can overcome our system’s lapses and improve performance through systematic, organized, and purposeful use of “systems” and “systems thinking.” By systematically applying data, we can organize in teams to provide answers, tamp down variables, strive for zero defects, coordinate everyone through e-systems, and put all relevant data at physicians’ fingertips in the exam room.

What we need to do, Halvorson stresses, is stick to the fundamentals --measuring, analyzing, improving, and controlling the system’s moving parts – and systematically re-engineering to target and modify constantly moving health care changes. I commend Halvorson’s presentation for your review. You can find both the PowerPoint and video versions by googling “George C. Halvorson, World Bank.”

But alas, the chasm between “what is” – only 10-12% of U.S. doctors in integrated systems, only 20% using electronic health records, only 20% communicating with patients by e-mail – and “what ought to be” – doctors working in large systems electronic records giving them unlimited accessibility to compliance, follow-up, and outcomes data – still yawns wide.

But who knows? Maybe someday we will get there. In the meantime, thinking and practicing in system-oriented organizations will help reduce costs, rationalize care, and improve outcomes. Until then, the Kaiser model, which serves slightly less than 3% of Americans, will serve as an experimental model of what can be done when professionals with a vision work together.


Dr. Val said...

George Lundberg believes that a "Kaiser America" plan has merit. (I.e. that we use the Kaiser model to provide universal coverage) Would you agree?

Mark Graban said...

Are the slides available online anywhere?

Bob said...

One may get the Halverson slides by googling "George C. Halverson" "world bank." The first hit will be the ppt slides. They are excellent. I'm very impressed by the discussion here about the Halverson slides, as well as the prior Lean Toyota discussion. Keep up the good work. If you wish to read more about LEAN healthcare, please see the book "Stop Rising Healthcare Costs Using Toyota Lean Production Methods" at the bookstore at I am the author of that book. Thanks for the great Halverson discussion. Great stuff. Bob Chalice

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