13 Books That Will Improve Healthcare

4. Mistake Proofing for Lean Healthcare, by Rona Consulting Group and Productivity Press, Samuel Carlson, MD, FACP and Maura May, Editors, CRC Press 2015

When healthcare professionals want to focus on a single operations practice that can have immediate group-wide impact, mistake proofing is a great candidate.  Every professional wants to believe the good works they perform - patient care, pharmaceuticals management, surgeries, emergency care - are not undone further down the line by errors.  But it happens, and the percentages, by some estimates one in 10 patients experience some sort of error, are not only scary, but they tend to induce organizational fixes and do-overs that do not guarantee a repeat.  How much more effective is Mistake Proofing for Lean Healthcare's basic approach to learning and maintaining A Better Way.

Readers may be interested in the industrial origians of this approach to healthcare - sectors like automotive and electronics have for seven or eight decades studied and improved their processes as originally measured by very basic quality management numbers.  Section 3.4, What Causes Defects, and Communication Errors, as well as all material on Zero Defects and Poke-yoke will prove to be invaluable to the team.  

My favorite keystone chapter,"Basic Elements of the Mistake-Proofing System," Chapter 4, will be a key learning revisited again and again, because it takes us right down into the proven methodology. Be aware that The Four Elements of Mistake Proofing includes 100% inspection, an approach that many expert industrial users have been able to set aside, but for healthcare, this is the recommended place to start.  

Mistake Proofing is formatted as a learning tool with each chapter containing good graphics and learning guides.  The Appendix contains recommendation for further reading and useful websites.  At less than 100 pages, this paperback will be well-worn and marked up as a great team-building and learning tool. 

5.  Just-in-Time for Healthcare,  Thomas L. Jackson, Editor, CRC Press  2017

Spent any time in an emergency room of late?  If you have, or if you've been rushed through an important appointment, you've got to be wondering "Isn't there a better way?"  And thanks to the pioneers of manufacturing, the answer is yes there is!  And what's even better, is there is a humanity to the whole medical system that companies are still struggling to re-inject into their processes?  The boom in analytics, robotics and AI will at some point only help institutions get great, but they have to get better first.  That's why Just-in-Time for Healthcare is such a great little resource.  Short, readable, in a clean format that helps working people process and remember the key points of lean healthcare.  Look for a Summary, good simple illustrations and Reflections in each of the book's seven chapters.  

Look at Chapter 2, for instance, which covers the industrial origins of lean healthcare and the important takeaways for healthcare institutions - the 7 Wastes, how to spot and identify wastes in healthcare, and most important, how to observe and analyze a healthcare "production" process.  Readers may see overwhelming complexity at first, but the actual true production process can eventually be discerned and separated from excesses.  The concept of takt time and standard flow may be of interest, but by far the most valuable lessons that will come from practicing the principles in this book are learning how to observe, mapping the flows and taking data.  As Dorian Shainin hammered into us, "Let the numbers lead you!"

6.  Healthcare Kaizen, Engaging Front-Line Staff in Sustainable Continuous Improvements, by Mark Graban and Joseph E. Swartz, with a Foreword by Masaaki Imai, and Introduction by Norman Bodek, CRC Press 2012

Kaizen is not all the US healthcare system needs, but this book is a great starting point.  The authors provide some history for perspective on the origins of kaizen in manufacturing, but they translate the methods US manufacturers perfected into usable healthcare tools.  Readers will like Section 1 with it's basic discussions of the history and principles behind kaizen, with emphasis on what has become a popular starting point, the suggestion system.  

From there Section 2, Kaizen Methodologies, will take the reader to some choices.  By starting small, adopters will find interesting data, good reporting structure, and hopefully positive group dynamics.  This is a great discovery stage that will help set the agenda for on-going kaizen work.  

Section 3, Kaizen Lessons Learned, covers how to tell if you are doing well, and helps groups sell and engage more kaizen work.  It also offers a good look at leadership styles and implementation approaches for lasting impact.  Although it may be true that certain industrial challenges could just as well be studied and solved by a handful of empowered industrial engineers, remember that the emphasis on kaizen is understanding and improvement among ALL the workers.  In post World War II Japan, where industrial engineers and intact factories were scarce, kaizen provided some answers.  And in stalled out US manufacturers and overburdened healthcare operations, especially those not completely dependent on tech, kaizen opens many possible paths to improvements.  In US healthcare, a growing sector dependent on both human and technology assets, the learnings we have accumulated in US factories are valuable.  

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7.  5S for Healthcare, from the Lean Tools for Healthcare Series, by Ronda Consulting Group & Productivity Press,  Thomas L. Jackson, Editor, 2009Love this little book!  In less than 2 hours this book will give healthcare professionals, and CEO's who take the time, the basics of a very basic discipline toward designed to clarify and structure a great workplace.  If you like throwing things out and periodic purges, you'll love this book.  If you are hoarder, or you've got hoarding tendencies, this book will challenge your approach to your "things."  

What are the 5 Ss?  Sort, Set in Order, Shine, Standardize, and Sustain

It's lovely, satisfying, and oh so revealing.  Take Sort, for instance - the author urges us to look around and classify items - equipment, supplies, even people ! - removing those items that are not necessary in healthcare operations for clinical or administrative processes.  Do you really need that corner supply cart filled with expired painkillers?  Probably not!  And because they should all be controlled centrally, they need to move.  And how about that adjustable crutches in the rehab center?  How about that box under the desk filled with who knows what paper forms?  Untouched in 3 generations?  Probably doesn't need to be there cluttering and germifying the environment.  Teams have great fun discovering and classifying these wastes.

Set In Order raises the difficulty level because users are asked to think about best arrangement for safety and productivity of the vital tools.  The perfect illustration here is a pegboard armed with carpenter tools, each one clearly outlined and pegged into its proper place.

Shine should not be a challenge in healthcare operations, but in some areas it may in fact be.  While Shine means to sweep floors, clean equipment and workers!

Standardize - Finally, to standardize opens the possibility of some equipment arguments.  See "Do you prefer the blue or the white gloves?" (Blue Heron Journal and AME's Target magazine)  Every surgeon has his own favorite tools and fixes; so do nurses, but the waste-elimination challenge of Standardization calls us to think carefully about eliminating variety and product variation in operations.  In manufacturing, extreme product variety creates piles of unwanted inventories; in healthcare, the same waste can happen, as well as the extra burden of ordering and maintaining a redundant supply chain.  The costs continue to pile up.  

Each section is illustrated with photos and sketches of examples - the good the bad and the ugly.  Further, readers will find helpful teaming and leadership recommendations throughout the book.  7.2.2.1, for example, covers the basics that supervisors and managers can offer to move projects toward success, and to employ and train new kaizen team members.  

What I've always loved about 5S is that is simple and movable - 5S works in factories, in hospitals, in horse barns, at home.  5S is always rewarding and satisfying, and gives us the boost to take on the more impossible challenges.  5S is a great confidence builder and a good place to bring team members together.

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8.  Process Improvement with Electronic Health Records, A Stepwise Approach to Workflow and Process Management, by Margret Amatayakul, CRC Press 2012

Healthcare electronic records pioneers discovered the same phenomenon that early manufacturing systems people found:  automating a bad process doesn't make sense.  Therefore, says author Amatayakul, this book looks at workflow and process management for EHR in a way that fosters improvement.  "The clinical transformation that an EHR is expected to bring about is not just the movement from paper to electronic documentation.  It is technology that contributes to a fundamental change in how medicine is practiced. "  When electronic systems are installed in large healthcare operations, they require guides to correct and navigate critical areas.  Expect that some healthcare people will adopt and support electronic systems sooner than others - in fact the implementation may take months.  The author quotes an Institute of Medicine 1991 study on computer-based patient records that found "merely automating the form, content, and procedures of current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs."

What's a patient to expect, therefore, when working with electronic records interspersed with human work processes?  It's a mix, but experts agree that reviewing key work processes in advance of system implementation may produce clarity and reduce paperwork.  

Process Improvement chapters set the stage for a ten-step approach to applying workflow and process management principles at various stages of an operation's development.  Each chapter includes specific guidance and tools, as well as case stuy examples.  The idea is to encourage a "see one, do one" approach to change.

Before system implementation, the author presents much detail on mapping work flows.  For example, "Table 4.3a Generic List of Hospital Processes" lists all the steps, in sequence, for a patient stay, started with Patient Registration, through Nursing Assessment, Medication Management, Diagnostic Studies, Surgery, Education, Discharge, Revenue Cycle, and Followup.  Just this one list of critical milestones could easily be transacted over multiple manual and electronic systems.  Until users observe and map the actual processes, however, the process flows will be unclear and possibly redundant.  

After mapping and problem identification, Step 9:  Implement Redesigned Workflows and Processes,  moves to establish best flows, and integrate them into the system.  These moves typically involve change that affects how and when work is done, and the author notes that there may be resistance.  Further, the process may be iterative as team members repeat, examine, and repeat new flows in advance of launching a system.  The author's section on change agents, particularly Table 11.3, Tips to Empower Workers, will help operations pick up speed with minimum emotional turmoil and resistance. 

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9.  Standard Work for Lean Healthcare, by Rona Consulting Group & Productivity Press, Thomas L. Jackson, Editor, CRC Press 2012

This simple little book makes an enormous contribution to the body of knowledge around delivering the best healthcare practices possible.  Unfortunately, standards, the detailed step by step description of the very defined ways a particular operation or service

 is performed in industrial operations, are not well understood or accepted in healthcare - if they were, standards would be dictating a whole range of patient-focused practices, from admissions and testing, down through diagnosis, treatment and follow-up, because even the best healthcare systems show signs of uncontrolled variation around communications and practice.  Observers wonder if this stems from the art vs. science argument, but we manufacturing people know better!

Standard Work for Lean Healthcare answers the question "Why are standards so important?" and "what are standards in healthcare?" while it offers easy to use charts and thought questions to keep moving.  Readers will especially like Chapter 4 Standardization, in particular the heart of the discipline, 4.5.2 Stages of Standards Improvement,  showing the actual process of standardization, step by step.  Along the way readers will see actual work charts, load and inventory illustrations, which they may or may not choose to apply in healthcare, but the very basic standards methodology will be invaluable for improvement.  

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10.  Getting to Standard Work in Healthcare, Using TWI to Create a Foundation for Quality Care, by Patrick Graupp and Martha Purrier, RN, with a Foreword by Gary Kaplan, CRC Press 2013

For readers on the front lines in healthcare operations, Getting to Standard Work will be more attractive than other resources because it is written by and for actual healthcare workers - coauthor Martha Purrier was in fact a pioneering RN at Virginia Mason Medical Center in Seattle, and co-author Patrick Graupp, a TWI consultant and educator.  The combination of actual healthcare experience with TWI methodology is impressive and makes the entire standards discussion more relevant, comfortable and usable to healthcare adopters.

Pay particular attention as you work through the chapters to behind TWI (Training Within Industry), the WWII industrial engineering methodology that allowed the US to ramp up from a depression-era giant to a mass producer that flooded the military supply chain with armaments, supplies, food, military men and women, and continued very structured training.  As a precursor to TPS, TWI offers us another framework for improvement, one that was proven across multiple sections - i.e. not just the Japanese blitz'd and struggling to recover auto industry.  

By focusing on the Virginia Mason Medical Center the authors introduced a single example of good training - a proper hand hygiene technique - so that we see the framework in its simplest and most powerful example.  Why would this simple training technique work as well, across an entire healthcare institution for equally dangerous patient processes such as pharmacy, pre-op, surgical services, labor and delivery, inpatient nursing, and equipment installation?  (I daresay that the abusive nurse I had post-op might have delivered at least the right level of medication had she completed and been certified in the hospital's new IT patient records system!  She might at least have known what my 9 1/2 hour surgery was!  But somehow she, unlike the physicians, lab techs, nurses, even receptionists, etc., had not gone through a basic Introduction to Our Brand New Patient Records System.  Shocking!)  

Following the powerful Hand-washing Hygiene example, the authors add more teaching tools in succeeding chapters, including The Four Steps of Job Instruction.  "Breaking Down a Job for Training" is a wonderful tool that allows trainers and students to identify the most important steps and to document results in breakdown sheets and standardized work.  (It's all industrial engineering, but presented in a palatable, small pill dosages!)

I love this book because it's usable.  The final section reiterates how to introduce and support TWI techniques into the general culture:

*  start small

*  stay true to the method

*  advertise results

*  create pull for more training and flow that demand.

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11.   Leading the Lean Healthcare Journey, Driving Culture Change to Increase Value, by Joan Wellman, Patrick Hagan, and Howard Jeffries, MD., CRC Press 2011

The results are in the numbers.  Here is the summary of the healthcare institution results covered in Leading the Lean Healthcare Journey:

*  How medium non-operting time in an operating room was cut from seventy-four to thirty-seven minutes

*  How catheter-associated bloodstream infections were significantly reduced

*  How the number of operating room documents was steadily sliced from twenty-one to fourteen to eight, freeing the staff to focus more intently on patients

*  How a revamped and reorganized work flow in a lab trimmed overtime by 25 percent and boosted productivity by 5 percent

*  How a 400-square foot supply repository costing $4000 per square foot went from a littered storage space to a seven figure-generating operating room

*  How a research review board cut its approval process down, from 86  days to 466 days, by eliminating thirty-five steps

*  How a research review board cut its approval process down, from 86 days to 46.5 days, by eliminating thirty-five steps

*  How a behavioral medicine department was able to overhaul its processes and procedures in order to see more patients

*  How a newly thought out registration-to-cash value stream ended up saving millions of dollars

*  How a new approach to total parenteral nutrition order writing dramatically reduced errors

*  How supervising nurses, who were spending 90 percent of their time reading e-mails, transformed their jobs so they could spend 50 percent of their time on the floor working with staff and caring for patients

*  How infections, over utilization, and confusion stemming from the use of peripherally inserted central catheter lines were addressed and reversed.

Be warned, the types of results listed above are impressive and powerful, but the strategic decisions behind these projects required much work. . This is a tough book.  Readers will recognize the names of Seattle Children's Hospital (See Seattle Children's, AME Target magazine and Blue Heron Journal)  as well as Jefferson Healthcare, The Everett Clinic, Memorial Care, and Minnesota Children's Hospital.  

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12.  Lean Leadership for Healthcare, Approaches to Lean Transformation, by Ronald G. Bercaw, CRC Press 2013

If you're already familiar with the basic lean tools - kaizen, 5S, hoshin kanri, value stream mapping, etc., this landmark book still offers additional resources for healthcare professionals and teams looking to initiative big change.  There are helpful suggestions on new ideas to help organizations shift, such as the Book of the Month Club, and Change Agent selection, although at this point we must be very careful with the over-used words "change agent," "culture change," "change is hard," "lasting change," "resistance to change," etc etc.  because too many organizations have wasted valuable opportunities and human energy focusing on the change phenomenon, and not enough on data, mapping, and movement forward.  

Better to focus on the interesting challenges that will be revealed from studying healthcare processes, and the challenge - and opportunity - of developing new ones.  Just about everything we touch in healthcare has big downstream impact, so we need to chose targets well.  Author Bercaw offers various reassuring recommendations to help protect the process and avoid the ever-loving politics.  Read the book mostly in sequence, paying especial attention to Chapter 3 section on "Getting Ready," Use the end-of-chapter Key Points to summarize learnings and look ahead to the coming phase - Lean Leadership is enough to start a healthcare team on the road to redesign of processes and delivery systems. 

 Although the book appeared a scant four years ago - 2013 - it would be good to have a post-Obamacare update.  We'd like to see the impact on medical records' IT systems linked to typical manual patient care delivery processes.  We'd also like to understand, of the endless improvement opportunities available in healthcare operations, which ones have the most impact on rising healthcare costs, and which ones most definitely raise safety results.

13.  Demystifying Big Data and Machine Learning for Healthcare, by Natarajan, Frenzel and Smaltz, CRC Press 2017

Not surprisingly, there are few titles that demystify big data, especially for the healthcare sector.  This volume, however, makes inroads on a new tech area discussed much at recent MIT conferences, so we know that eventually machine learning and big data will be an essential for healthcare IT.  From understanding exactly what decisions can and should be made using big data, to showing through illustrations and case studies exactly what the output should look like, this book offers a shorter path to "trying out" this new data technology.

The authors cite as one of their three 2013 catalysts to write this book a successful analytics transformation at MD Anderson, the world famous cancer center.  Natarajan reminds us that worldwide revenues for big data and business analytics are forecast to grow from nearly $122B in 2015 to $187B in 2019.  And he says that healthcare is also in the throes of a data revolution, with "... forty percent of new applications aimed at direct health interventions or predictive capabilities," so the market potential and the money are there.  

But what is most impressive in this book are the case studies.  It's difficult enough to imagine this kind of tech transition in healthcare without war stories, good and bad.  So the back half of the book is nicely dedicated to a group of case studies - 

1.  Penn Medicine:  Precision Medicine and Big Data, by Brian Wells

2.  Ascension:  Our Advanced Analytics Journey, by Tony Byram

3.  University of Texas MD Anderson:  Streaming Analytics, by John Frenzel

4.  US. Health Insurance Organization:  Financial Reporting with Big Data, by Mar Perlman, Larry Manno, and Shalin Saini

5.  CIAPM::  California Initiative to Advance Precision Medicine, by Eizabeth Baca

6.  University of California San Francisco:  AI for Imaging of Neurological Emergencies by Prazik Mukkerjee

7.  BayCare Health System:  Actionable, Agile Analytics Using Data Variety, by Aparsmy Balaji

8  Arterys:  Deep Learning for Medical Imaging, by Carla Leibowitz  

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Patricia E. Moody

FORTUNE magazine  "Pioneering Woman in Mfg" 

IndustryWeek IdeaXchange Xpert

A Mill Girl at Blue Heron Journal, on-line resource for business thought-leaders and decision-makers tricia@patriciaemoody.com, patriciaemoody@gmail.com, pemoody@aol.com