In the era of value-based health care, reducing waste and decreasing cost is a priority for health care systems. A primary challenge in improving health care value is to maintain or improve outcomes while reducing the cost of care. Lean Production, widely used in manufacturing industries, aims to reduce cost and eliminate waste and can be used to achieve similar ends in medicine. By assimilating these principles, health care systems can identify wasteful processes to further the Triple Aim (improve outcomes, reduce costs, and improve patient experience).
At Oregon Health & Science University, an initiative was created to evaluate the efficacy of imaging obtained by the neuroscience service line and limit nonessential images. A single standardized procedure, retrosigmoid craniectomy for microvascular decompression, was analyzed. Retrospective analyses of institutional data were performed prior to prospective changes in clinical practice. Data collected after implementation of the clinical changes demonstrated similar outcomes and reduced cost, thereby increasing value.
KeywordsPostoperative imaging, Head CT, Value, Waste reduction, Cost-effectiveness
With the passage of the Affordable Care Act in 2010, the American Healthcare system has placed an imperative to improve population health with better medical outcomes, to reduce the per capita cost of health care, and to improve the patient experience of health care. These three ideas form what has been described as the Triple Aim. Partly due to changes in reimbursement for health care delivery, hospitals and hospital systems have placed substantial resources in furthering these three goals. Multiple methodologies from the business and manufacturing world have now found themselves being used by hospitals as a mechanism to make health care delivery and patient care more efficient by improving quality and controlling or reducing costs. These include Lean, Six Sigma, Continuous Quality Improvement, Total Quality Management, and Plan-Do-Study-Act. By adopting these principles in health care, patient outcomes can be improved, and costs can be reduced.
Lean, also known as Lean Manufacturing or Lean Production, is a method for waste minimization within a manufacturing system without sacrificing productivity. This process was originally derived from the Toyota Motor Corporation production line. With better inventory management, identification and reduction of waste, standardization of procedures, and the creation of a culture of continuous, incremental improvement, the company created a world-class economic enterprise. Adapting these concepts to health care is difficult, but the organizations that have done so have seen not only significant increases in their abilities to care for patients but also significant reductions in the cost of delivering that care. For example, in 2012, a Dutch Internal Medicine group at an academic institution published a 13% reduction in the total diagnostic costs over a one year period. These diagnostic cost reductions (radiology, laboratory tests, microbiology, nuclear medicine, and pathology) amounted to 350,000 Euros in 2009. In addition, there was no change in patient outcomes, readmission rates, or mortality rates. They were able to do this by first identifying and defining the existing workflow, instituting changes in practice, and then observing those changes over time.
At Oregon Health & Science University (OHSU), Lean has been adopted to improve the quality of patient care throughout the hospital organization. In addition to projects aimed at reducing complications of care such as central line infections, venous thromboembolic events, and hospital readmissions, ongoing projects aim to reduce operating room turnover times and decrease surgical material waste. In the neuroscience service line (NSL), a project was initiated to evaluate the use of imaging for patient care with the goal of potentially reducing unnecessary imaging studies. The NSL includes providers from the departments of Neurosurgery, Neurology, Anesthesia and Perioperative Medicine (for providers in the Neurosciences ICU), and Orthopedics and Rehabilitation (as ICU level care for complex spine patients is provided by the Neurosciences ICU). This resident-led program was the pilot study commissioned by the university known as Value Improvement Resident Training in the University Environment (VIRTUE) which provided the assistance of an Electronic Health Record analyst to produce and parse data for the study.
Initially, the goal of this pilot VIRTUE project was to assess whether or not residents were ordering imaging studies that did not produce value for the patient. The study group examined all of the imaging studies obtained in the NSL over a period of 18 months. Approximately 5100 total studies were obtained. These images included CT and MRI of the brain and spine. It was found that noncontrast head CTs (HCTs) made up the majority of the imaging studies obtained in the NSL. 3124 HCTs were obtained during the period examined. These CTs were parsed according to the time of day obtained. We defined daytime hours from 0700 to 1700 to account for the most common hours during which there would be direct attending supervision. In addition, the number of CTs obtained on the weekend vs the weekday was analyzed. We defined the weekend as 1701 Friday to 0659 Monday. We determined that there was no significant difference between the number of daytime and evening scans ( Fig. 19.1 ) and there was also no difference between the proportion of scans obtained during the weekday or during the weekend ( Fig. 19.2 ). After further review of the data, we determined that greater than 50% of HCTs were obtained for patients who had a single routine postoperative HCT. However, only in a very small number of cases did findings on the postoperative HCT combined with a deterioration in clinical condition prompt an intervention. We sought to evaluate what value these routine postoperative HCTs provided to the patient. The first step was to define the current state by providing data to support a potential change in practice.