When Committees Oversee Standard Work

Standard work, a core component of lean, creates consistency of process and outcome.  Developing standard work based on data and analysis is critical, as opposed to simply documenting what is currently done.  But what happens if the analysis and data is there, but "higher authorities" effectively over-rule or discount the analysis?  An intriguing article in the WSJ earlier this week looks at one possibility from the health care arena.

The first three or four hours after a stroke are the most crucial. For most stroke patients, receiving a clot-dissolving drug shortly after arriving at a hospital can reduce the effects of stroke and limit permanent disabilities. But for some patients, with a certain type of stroke, such a drug can actually increase bleeding in the brain and boost the risk of death. Stroke experts say the best way to tell which patients should get the drug is by having a CT scan of their heads read within 45 minutes of their landing in the emergency room.

Stroke doctors like to say that "time is brain," meaning the faster a stroke is treated, the more likely treatment will lead to complete recovery or at most mild disability. In the most common type of stroke, in which a clot blocks blood flow to the brain, studies show that quick administration of the drug tPA, or tissue plasminogen activator, can improve outcomes.

But because tPA can cause bleeding, it's precisely the wrong treatment for strokes caused by a brain hemorrhage. Treatment for hemorrhagic-stroke patients aims to relieve pressure on the brain, including with surgery or medication. The CT image is pivotal in determining which course of treatment is called for.

Sounds pretty obvious.  CT scans are quick and easy, available in every reputable clinic, and relatively inexpensive compared to the potential consequences.  At least you'd think so...

But a rule that would call for a scan within 45 minutes was rejected last fall by a quasi-governmental group that sets medical guidelines used by Medicare to evaluate and reimburse U.S. hospitals. The group, known as the National Quality Forum, said the vague wording of the rule raised too many questions.

So a good policy, one that can save lives, one that is pretty obvious, gets killed due to "vague wording"... in itself vague.

Stroke neurologists say the forum's rejection of the 45-minute CT-scan rule threatens to compromise stroke care nationwide, possibly resulting in more deaths and disabilities among stroke patients. Hospitals that receive Medicare funding will have to begin publicly reporting as early as next year how well they comply with other stroke-treatment guidelines, but need make no mention of whether they perform CT scans.

Stephen M. Sergay, president of the American Academy of Neurology, wrote to Ms. Corrigan last summer saying the committee "lacks the appropriate qualified personnel to evaluate such a critical issue."

I won't dive into it, but to most of us it's obvious: welcome to the future of bureaucrat-run health care.

Comments

[Tom Schaaf MD]

If you read the article there is a very real problem with how you define the starting point of the process to get the appropriate specificity of the process measure. I would not want my hospital rewarded or punished based on a poorly thought out measurement system. I agree with the 45 minute measure in principle, but I have to know when to start the clock to assess performance.

[Ram]

While I have no interest in defending bureaucratic incompetence, the author ignores the glaring problems with the current for-profit and non-profit health care system.

The National Institutes of Health estimate conservatively that 40,000 Americans die each year due in part to preventable medical errors. That's like having a 9/11 attack almost every month. Many of these errors could be avoided if physician administrators chose to implement simple procedural changes in hospitals, pharmacies, and clinics.

So it cannot be said that the current system is ideal, or that it is diligently protecting patients.

[Rick Bohan]

What, exactly, IS a "quasi-governmental group"? I'm guessing it's any organization that WSJ doesn't agree with.