Improving patients' care in hospitals

Monday 30 December 2013 5:30PM (view full episode)

Although technical advancements have allowed healthcare workers to deliver high levels of care, there are still many problems in the way patients are cared for in hospitals, which need to be improved. This program is a repeat. It was first broadcast on 20 May, 2013.

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Norman Swan: Hello, and welcome to the Health Report with me, Norman Swan. Today's program is about making healthcare safer by increasing efficiency, reducing waste, and putting in place systems to ensure the right thing is done to us when we are patients. Dr Terry Platchek of Stanford University in California came to this view, as many have done, through tragedy when he was an intern.

Terry Platchek: I was taking care of a patient who was being admitted with dehydration. She had something called congestive heart failure, so her heart didn't pump quite as well. So when I got called up from the ED consultant they said, 'We've given her a little bit of fluids gingerly and we want to watch her real closely. She's got a lot of diarrhoea, so we're going to admit her up to the ICU,' and I thought, great, it sounds like it's easy-peasy, I'll drip in the fluids slowly, we'll get her diarrhoea better and this will go quite well.

She came up, a very pleasant lady, had a long conversation with her, and we were having a hard time keeping an IV in her. I called up my consultant, ran the case by him, said, 'Sounds great, doing the right thing.' My senior resident (in Australia you call it the senior reg) was downstairs in the cardiovascular ICU, called him up and said, 'Looks like we have to put a line in,' he said, 'Okay, get all the supplies together, I'll come up we'll do it together.'

I got all the supplies together, put the patient under a sterile drape. I was pretty new to the process so it took maybe 45 minutes to put the line in. And we took off the drape, everything went perfectly well and we saw the patient and we couldn't arouse her. We ended up calling code, a medical emergency team, and tried to resuscitate her and she passed away. I was pretty devastated. In post-hoc analysis she had something called clostridium difficile…

Norman Swan: Is that for antibiotics you get this diarrhoea?

Terry Platchek: Yes, and of course I was a first-year junior doctor so I wasn't as familiar with it as I should be, that there was a more virulent form, a higher toxin form of the bacteria, and she actually got it into her bloodstream. She didn't just have diarrhoea, she had sepsis. And had I been more experienced or more astute, maybe I would have caught the fact that she was physiologically unable to respond to the fact that she had a massive infection.

I was depressed. I was depressed for months, and I talked about it with my advisor, one of my mentors. And he sat down and he said, 'Terry, you're never going to get over this,' and I still haven't. He said 'there's two things you can do; you can wallow in your sorrow, or you can look at the system that allowed this to happen, because you weren't the only thing that went wrong, there were lots of clinicians involved in that care process, there were lots of misses. The nurses could have picked up on something. Your supervising physicians could have picked up on something. We could have diagnosed earlier that it wasn't just diarrhoea and gotten the tests that would have shown that she was actually having sepsis. There was a whole host of systematic errors that occurred that allowed this horrible thing to happen to your patient.' And I can't ever let this happen to another one of my patients.

I'm dedicated to the notion that we have to have systems that support very dedicated healthcare workers, that support them in their work rather than make it more difficult for them to do their work. The system should help us identify when things aren't going right. And right now the system is usually the reason why things aren't going right. I don't think it's about the people in healthcare. There are fantastic people that are working in healthcare. In Australia, in Canada, the UK, the United States, everywhere I've gone the best and the brightest are in healthcare. The issue is we're trying to put our best and our brightest people in a bunch of processes that are designed for failure, and you get mediocre results that cost a fair amount of money. So that's my new life's challenge; fixing care processes.

Norman Swan: Terry Platchek, who is now a paediatrician at the Lucile Packard Children's Hospital, which is part of Stanford University's medical centre in California.

And this is the Health Report here on RN with me, Norman Swan.

Terry is among an international group of health professionals who have adapted, rather amazingly, the statistical and analytic techniques used by Toyota to improve the quality of their car manufacturing. Toyota does or did this by breaking down the process into tiny parts with the front-line workers, and not giving up until they'd truly identified the problem. Then they'd help the workers to find solutions and feedback data which improves the solutions themselves over time. In healthcare it's often called lean thinking.

Terry Platchek: When I first heard about it I thought it was a way of reducing costs in healthcare, I thought it was about, in an innovative way, just taking ideas from the front-line and trying to turn them into solutions to problems. I didn't really understand that it was actually more about quality in any complicated system and how you deliver that quality at the lowest cost, so how you create value in any sort of complex organisation.

Norman Swan: So give me some stories about what you've done at Stanford?

Terry Platchek: Stanford started its journey, both the adult hospital and the Children's Hospital around within the past three years, so my job is primarily at the Children's Hospital. I think our most developed areas are within our perioperative services, and in those areas we spend a lot of time just trying to achieve basic stability around processes. That can be as simple as trying to level the amount of patients that are coming out of theatre and other areas of anaesthesia into our post-anaesthesia care unit so that they weren't getting to be a bottleneck and were shutting down the operating theatres, and people who had been without anything to eat for eight hours are now going to have to wait another four because we can't manage to get patients out of…

Norman Swan: So the problem was essentially queueing from the operating theatre to get into the recovery rooms. Sounds extraordinary.

Terry Platchek: Yes. The baseline standard in the US that you will often hear quoted is you should have three anaesthesia recovery beds for every one area where you are providing anaesthesia. So at Packard we have around a one-to-one ratio and everyone said, oh, you're crazy. Well, now actually we've gotten that sorted, we are about ready to shut down a number of our beds because we actually found that we don't need them.

Norman Swan: So in other words you were operating on a third of the number of the beds, according to the received wisdom.

Terry Platchek: That's right.

Norman Swan: Let's back up, describe the problem in more detail, because people don't really understand what goes on in theatres.

Terry Platchek: So the problem is, you're a patient and you are booked to come into theatre at 2 o'clock in the afternoon, you haven't eaten anything all day, and you get informed, 'It's going to be a couple of hours wait, we're delayed,' or even worse, 'We're cancelled because we just couldn't get through the patients that we needed to today, come back tomorrow or come back next week.' And we started to look at that and say why is this happening.

And when you examined it you found a big issue was in the recovery area we couldn't get patients out, or wherever it was that they were going, whether they were being admitted to hospital or they were going home, for some reason we couldn't manage to get them out, and so we couldn't manage to take the new patients in. And sometimes even if we had a bed to take someone in, we didn't have a nurse to be able to take them because there were too many patients coming in from across the hospital at the same time.

And so we started to say how can we fix that. Now, this wasn't me, this was the people in our perioperative services saying how can we fix that. And so they said we need to level the flow, we need to find a way so that patients are coming out of areas of anaesthesia, the operating rooms, MRI in paediatric patients, they often need to be sedated, or ambulatory procedures such as when they are getting a catheter placed. We need to have a flow such that every 20 minutes a patient is coming out, so that we always can have a nurse available to take them and we don't shut down our operating theatres, and so patients don't get told 'you have to wait' or 'you have to go home'.

Two years later we are doing a fantastic job. We are at the point where we are even saying all those beds that we thought we needed, everyone else said we needed triple and we were never going to be able to solve the problem…

Norman Swan: The problem as defined by the patient going through it is you're either sitting around starving for another two hours or getting more dehydrated and presumably not doing as well, or you are being sent home. But when you looked at the problem, the problem was not even that there wasn't a landing slot in theatre, there wasn't a landing slot from theatre and people were arguing, well, we just need to build more recovery rooms and put in more beds because that's the problem.

Terry Platchek: That's exactly right. And in the United States, I should say, we are not doing nearly as well as Australia. We're spending 18% of our gross domestic product on healthcare, Australia is somewhere around 10%.

Norman Swan: So you ask the question; do you actually need more beds or is it a process problem?

Terry Platchek: That's exactly right.

Norman Swan: So how did they change it so that instead of this flood of patients into the recovery room you actually got landing slots that were more organised?

Terry Platchek: They did some just amazingly innovative things that were extremely simple. They started looking to schedule cases based on when they thought the case was going to end, as opposed to when they thought the case was going to start. And then they tried to align it so that in any particular timeslot they don't have more than three cases coming back to the PACU, because all they have are the three nurses. And they established a time that they thought was a reasonable amount of time to recover patients in PACU, 80 minutes, such that you'd receive a patient, you'd get them settled, then you'd continue on with their care. And then you were up again in 40 minutes to receive another patient. In that way a nurse could be constantly taking care of two patients, back and forth, back and forth, and the system would flow.

Norman Swan: And unless something really bad happened to the patient, you could tell the ward or their relative to come and pick them up at 3:30 because that's when they are going to be done.

Terry Platchek: That's exactly right.

Norman Swan: And how did they predict when theatre was going to end? I mean, some surgeons are slow, some surgeons are fast.

Terry Platchek: Still a problem people are working on. People do operate at different speeds and sometimes there are unexpected complications or findings in the case of an operation. What we realised though is that that's not an excuse to say that we can't even try. So are we 100% accurate? No. But they are getting more and more accurate to the point where the other week I was down there and I think they were about 70% accurate at predicting end times.

Norman Swan: So you're doing that now with a third of the number of the beds that is the norm in the United States.

Terry Platchek: That's right.

Norman Swan: And you're thinking of shutting down even more beds.

Terry Platchek: That's right. Where people are planning based on the inherent inefficiencies in a process, which are invisible, it's not easy to stand there and see, oh, there's a way that we can actually solve this problem, because so much of what goes on is siloed. You don't look at the way patients are flowing across perioperative services.

Norman Swan: So how did they solve the problem? How did they find out where the bottlenecks were? Because it's easy to say, well, it's recovery, they are not getting out of recovery, but that's still not the problem.

Terry Platchek: Well, they did two things. They took a step back and they looked at how do patients flow through all of our perioperative services, from when they come and they get checked in, to the pre-anaesthesia, to the theatre, to the post-anaesthesia and to where they are going. So they looked at that entire stream, and they started to say how long do we think each of these things should take? And it was a process of months and months of adjusting those numbers, but they had to start somewhere.

Norman Swan: So they walked through what happens to the patient on the trolley and they walked through that process analysing every detail.

Terry Platchek: That's exactly right, we call it a value stream or a patient journey, but that's exactly what it is, it's following the patient as opposed to staying at your station.

Norman Swan: And that's all it was, it was just timing in the end?

Terry Platchek: Well, that's an excellent question. You have to have some standard, and the standard is essentially a time, so that you know if you're not meeting it. When you're not meeting the standard…

Norman Swan: Then you need to find a way of meeting it.

Terry Platchek: That's exactly right. And so it might be that they have a broken form or there's a broken process or we are not doing this right or that right and you have to fix that. But unless you know what is expected you can never actually say, oh, what occurred isn't right.

Norman Swan: There's been a big controversy in Australia. We've had four-hour targets; from the moment you register at the emergency department when you come in off the street, you are supposed to have been dealt with by four hours, either to the ward or home. And people have said, well, this is going to compromise quality. You're giving us a time target here and we will compromise patient care by just meeting this four-hour target. How did you guarantee that just by sticking to these time targets in fact nobody died or went off?

Terry Platchek: So this is a fundamental question in systems redesign or operations engineering, I call it lean thinking, and that is how do you achieve flow while ensuring quality or while ensuring safety. I don't think that anyone in the Australian government is hoping that the four-hour target is going to have people cutting corners. The key is to use the four-hour target as a means to say we are not hitting our standard and to try and address the problems that are keeping you from hitting the standard safely rather than take shortcuts.

There's a couple of ways you can do this. You can put in quality tollgates, checks to make sure that every quality element is being kept in the process, and hopefully as you start to see that you are failing to meet your targets and you start to do analysis, what you do is you put in systems such that it makes it impossible to do the wrong thing, because humans are error prone.

Norman Swan: So give me an example of that.

Terry Platchek: Well, let me give you an example from anaesthesia. It used to be the case that patients died in theatre because the wrong gas was hooked up instead of oxygen. This was a horrible consequence, obviously, this is an extreme example.

Norman Swan: So they got tubes that are different colours and different plugs so that you couldn't actually attach the wrong gas to the wrong outlet. But it's more complicated in an emergency department when somebody might be coming in and because you're focusing on the target you miss the fact that they are having a heart attack or you miss the fact that they've got a low blood sugar and you send them home and they come back dead.

Terry Platchek: That's exactly right, it's much more complicated than that. But the basic premise is where you can you make it impossible to do the wrong thing, and where you can't you have to achieve visibility. So if someone is coming in with chest pain, we know there's lots of literature that has been described as to what the differential diagnosis is for that chest pain, and we know what you probably should be doing to work up that chest pain. There's lots of literature associated with it.

The issue is when you put a human in that position, even if they are an extraordinary human they are error prone. So you have to have a system that shows have we done all of those things that need to be done. We have to apply some sort of regimented standards across various presentations of illness.

Norman Swan: And your argument is that doesn't necessarily take any longer and it might take shorter because you've processed it rather than left it to chance.

Terry Platchek: People know what to expect. Now you can design entire systems to make that thing happen well. And if you have visibility around the fact when something isn't happening well…let's take an example from what I do, I take care of asthmatic patients, I spend a lot of time taking care of asthmatic patients wondering did they get the albuterol they were supposed to be getting, which is a medicine which helps…

Norman Swan: What we call Ventolin.

Terry Platchek: So did they get that medicine? I don't know. And so I'm looking for the chart to see whether or not they got the medicine because they are not getting better. What if it were impossible for them not to get that medicine, or it were extremely visually easily able to tell that they didn't get the medicine? Now I can say instead of wondering, well, is the reason why they are not getting better because they didn't get the medicine, I can say do I have the right diagnosis, do they actually have asthma, did maybe the child swallow a marble?

Norman Swan: And you've saved 10 minutes of your time.

Terry Platchek: Ten minutes, maybe an hour of my time, and you multiply that over the number of times I see an asthmatic getting admitted to hospital, all of a sudden now I can see two more patients a day, and each of the patients that I'm seeing is getting a better quality care.

Norman Swan: Describe to me your story of the MRI suites at the hospital. This is a most extraordinary story.

Terry Platchek: This is a great example, this is at the University of Michigan when I was there. One of the questions was should we build more MRI scanners. It's a really interesting question. These are very expensive machines, and medicine is relying more and more on them. Well, they looked and they said we just can't manage to get the patients through. There's a huge backlog, we need another scanner. Well, if you go down and actually look at the scanner, what's valuable is when that magnet is running, when some scan is happening, and what you do is just time over the course of a 24-hour period how often that magnet is on. I forget the exact number, but it was something like 30% of the time.

Norman Swan: So you've got this multimillion dollar scanner by the time you've added the bunker and everything that goes around it, but you're only getting benefit 30% of the time.

Terry Platchek: At least that's what I thought. We went and looked back, and the person who did the watching actually was looking at 24 hours of total operating time, but they were only doing it when people were staffing the MRI. So the MRI was only being staffed for about 12 hours, the other 12 hours it was down. So actually it was only 15% of the day that it was being used, and there were lots of reasons why it wasn't; the patient didn't arrive on time, or having to sedate the patient, or having to put them in the right place, or the fact that we are not running the scanner overnight. And so the question is do we want to spend…I don't know how much these things cost, $20 million more to build another scanner, or should we run it at night? And everyone says no one wants to come in at night. Actually, if you give people preference, some people because of when they work or whether they are a night owl or something like that, will choose to take the care late in the evening. They are actually thankful for it. And we saved however many millions of dollars from building another MRI scanner.

Norman Swan: But obviously if it's only being used 30% of the time during the day, even when you are slotting them in through the day, there is downtime which is presumably wasteful that you could eliminate as well.

Terry Platchek: That's right, and so when you have a simple measure, for instance how often the magnet is activated, you can look and say, well, why isn't the magnet running right now? Mrs So-and-so wasn't appropriately prepped, she is going to need to get sedation, and she ate, so we are going to have to send her back and we will call for the next patient. So here now we have a 40 minute delay. Well, why did that happen? Why did Mrs So-and-so not get the care that she needed that let her know that she wasn't supposed to be eating so that she could get the anaesthesia? We have to go upstairs, we have to look at the processes and we have to try to work on them. And one by one each reason gets surfaced, and then you go one by one and look and say why did this happen and how can we help this patient right now and keep it from ever happening again so that further patients don't experience this.

Norman Swan: So it becomes more like a production line. If you know somebody needs sedation, you've worked it out a couple of days beforehand and you put in the building blocks, if you like, to make sure that Mrs Smith arrives properly prepped.

Terry Platchek: That's exactly right, the process becomes like a production line, which is not to say that medical decision-making is like a production line. As a matter of fact I think it frees providers up to think more about why their patients aren't improving. Why is it that this patient is still sick when we expect that they should be getting better, and we know that the care that they are getting is exactly what we've prescribed, as opposed to questioning is the care that they are getting what we prescribed, now they can focus on even more important things like do we have the wrong diagnosis.

Norman Swan: You've also looked at the way doctors run their appointment system.

Terry Platchek: Yes, this is great. Colleagues both at Packard and other hospitals that I've worked at have looked at various ways that providers scheduled their appointments. You look at a particular clinic with a very senior provider who is extremely skilled and you say how can we get this provider to see as many patients as possible, because they are a scarce resource. And what ends up happening is the system gets designed around that provider.

Let me just take you through what a system like that looks like. So it's 1 o'clock, there's an afternoon session for the provider, in outpatients, and they are looking to see, let's say, 16 patients in an afternoon. And so they say four patients arrive at 1 o'clock, four patients arrive at 2 o'clock, four patients at three and four patients at four, so 16 patients come in. Well, why do they have for patients arriving at 1 o'clock? The reason for that is if one of the patients is a no-show or manages to be late, the thought is we don't want the provider not to have anyone else there to be seen. Well, here's the issue, if you ask four patients to come at 1 o'clock, you are mandating that the average wait time in the best of circumstances is 30 minutes.

And what do people do when they are sitting there for 30 minutes? They start to get upset, they start to feel like their time is being wasted, they start to think about all the things that are wrong with them and they get in to see their provider and they are all in a huff. Their blood pressure is up, they came up with a lot of questions which maybe they haven't even thought through because they are just upset that they had to wait so long…

Norman Swan: So the consultation takes longer and is less productive.

Terry Platchek: That's exactly right. The providers don't get to the important things that really matter for the patients, actually the reason why they wanted to come in in the first place, and they spend a lot of time doing this thing called service recovery. So the actual appointment visit takes longer and people are less satisfied. Now, if you have people arrive shortly before you expect them to be seen and you quickly bring them into the rooms, the appointment visits actually get shorter.

Norman Swan: Because the conversation is on the money.

Terry Platchek: Because the conversation is on the money. And if you look at it empirically, more patients actually can get seen.

Norman Swan: How difficult was it to get people to change to quarter-hourly bookings?

Terry Platchek: Well, the answer is we still have lots of providers that won't, so it continues to be difficult.

Norman Swan: So given that clinicians rule, particularly doctors rule, how do you change them? Because they can be cussed.

Terry Platchek: I firmly believe that everyone that has become a healthcare professional does it because they want to help the patients. The issue is you have a learned frustration with the system, and we all become experts at work-arounds for entirely broken processes, so expert in fact that we don't even realise…doctors in particular are very data responsive, and so I tell them, You see a patient, you don't jump to a conclusion about what they have, you take a history, do a physical exam and do diagnosis, and then you follow-up to see if the diagnosis was correct and if they are responding appropriately to treatments.

We have to look at problems in our processes in the exact same way. We don't want to jump to a solution before we've ever really understood what the problem is, we don't want to do it necessarily from a boardroom, we want to go to where the work is being done, look to see what problems are actually occurring, find out which ones are the most pertinent to work on and bring all of those folks that are at the front-line, the nurses, therapists, physicians, social workers, bring them altogether and say these are the problems we are seeing that are affecting our patients, how can we come together and design a better process so that there is less of these problems.

Norman Swan: They own the solution.

Terry Platchek: They own the problem and they own the solution.

Norman Swan: And you put a lot of store on defining the problem correctly.

Terry Platchek: I think it was Dorothea Brande who said that a problem well described is a problem half solved. I definitely believe that.

Norman Swan: Can you give me an example of people coming to misleading definitions of problems?

Terry Platchek: Yes. One of the big things I'm working on now at the Lucile Packard Children's Hospital at Stanford is ideal patient discharge. By that I mean I don't want to discharge patients faster for the sake of discharging them faster, I want them to be discharged perfectly, but I want to do it in the shortest amount of time possible, as soon as they are medically ready to go home, because the bed is expensive.

Norman Swan: And nobody wants to stay in hospital longer than they need to.

Terry Platchek: That's exactly right. It's dangerous. There's lots of resistant bacteria in a hospital, you don't want to be there if you don't have to be there. So when you start talking about this though, with even the most well-meaning physicians, nurses, administrators, there are 12 solutions that are thrown out; we need a discharge lounge, we need to have shuttles that will ferry patients home…

Norman Swan: So they've got an answer before they work out what the problem is.

Terry Platchek: That's exactly right. Or if they have seen the problem once they think, well, my experience is this problem occurs so that must be the most common problem. Instead of going and looking and counting and saying actually our most common problem is the fact that our medication reconciliation is taking long and that's the problem that we need to work on. Once you do that though people will say, well, I know what the problem is, the problem with med rec is X, Y and Z. Once again, it's a jump to solutions. There is probably actually seven or 12 or 30 reasons as to why the medication reconciliation doesn't occur correctly, and we need to look at all of them and find out what the most important ones are. We've all been trained since we were in kindergarten to jump to that answer as quick as possible, raise your hand and yell it out to the teacher and you are going to get rewarded. And this is a very difficult thing to un-train people to do.

Norman Swan: And accept that the solution will take a couple of years to come to fruition.

Terry Platchek: Well, I hope it doesn't take a couple of years, I'd like to get to the solutions as quick as possible, but we always underestimate the amount of time that it takes to solve problems once and for all as opposed to bandaiding.

Norman Swan: It's been said that what we do in a modern healthcare system, whether it be Australia or the United States or the UK, 30% is waste. Some of that waste is people doing unnecessary procedures, prescribing the wrong drugs and so on. How much of that 30% waste are the process issues that you've just been describing?

Terry Platchek: It's a very good question, and I don't know if I have the answer. In my experience when I've been redesigning processes and you describe the valuable steps, which means a step that provides a patient with treatment or that removes their pain or their suffering or gives them comfort, usually only about 5% of the steps or around 5% of the time spent in the entire process is value added.

Norman Swan: 5%?

Terry Platchek: Yes, think about it. So when you called your last GP because you had a cough that wouldn't go away, did they see you that hour? No, you probably waited. Even if you get seen that day or the very next day, which you think is a very good thing, all that wait, did that help you? No. There is no value that is being done by that. We could probably find out a better way, when you are calling up on the phone, to figure out if you need to be seen or if you don't need to be seen. And if you don't need to be seen, is there some treatment we can provide to you right now that might make you feel better?

There are some steps that don't produce value that are necessary. We have double checks, check lists ensuring quality, all these sorts of things are necessary, but if we can find a faster, easier way to do them, we should, because they are not providing value for our patients. So let's just look at the process of checking into the doctor. That's not a value stream, that's just a small little process. How much of that is actually valuable for the patient? So I think that there is a huge amount of 'waste' that can be taken out of most of the processes in healthcare.

Norman Swan: Again, using Australian data it's said that only 19% of the average nurse's time is spent in patient care. I assume it's similar in the United States. How do you improve that number so that somebody who is trained to be an expert clinician actually does what he or she is trained to do?

Terry Platchek: Yes, I think it is similar in the United States. I've seen places that are worse. I think the answer starts with saying first of all let's focus on the time they are not spending with the patients as opposed to spending all this time focusing on the time that they are spending on the patients. We do a lot of work on the 'value added' process, making that doctor visit go faster or making that nurse visit go faster. I'm interested in the other 81%, look at that, see what they are doing there, actually go and observe and say, okay, what if that time that they spent on things, what if that was providing value for the patients, and what can we eliminate right now?

Most processes in hospitals evolved. They might have been designed at one point or they might never have been designed. What we need to do is take a look at it and do some redesign, but we are not going to be able to do it until we focus on all those things that they are required to do right now which are not providing value. Doing the same thing three times because we need to put the information in three places. Should we have a paper medical administration record and an electronic medical administration record and then we also have to have another separate audit administration record? No, that doesn't make sense. We have to make the process work so that when they record that they have given the medicine, if we need to have it in three places it gets put in three places. All that time transferring all that information, that's waste.

Another example is pretty simple. How long does it take to find something in a medical closet? I mean, these things are just packed with stuff and you often have to push things out of the way to find what you need. Well, a little bit of time spent organising that closet and putting in a process so that it stays organised…and by that I mean…

Norman Swan: So when you want a 10ml syringe you know where to find a 10ml syringe.

Terry Platchek: That's exactly right. These are all examples of the myriad of things that can contribute to what essentially is sucking time out of our providers so that they can't spend it with their patients. They're not sitting around on their duffs, they are working hard. This is a marathon. We need to slow the pace, we need to make it so that it's easy to do the right thing, that it's very difficult to do the wrong thing. And in most care processes in any complex organisation, not just healthcare, it's usually much easier to do the wrong thing.

Norman Swan: Terry Platchek of Stanford University's Lucile Packard Children's Hospital.


Platchek T, Kim C Lean Health Care for the Hospitalist. Hospital Medicine Clinics 2012;1(1):e148-160


Dr Terry Platchek
Medical Director for Performance Improvement
Lucile Packard Children's Hospital
Fellowship Director
Clinical Excellence Research Center
Stanford University


Dr Norman Swan
Brigitte Seega

Comments (2)

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  • Larry Langman :

    30 Dec 2013 6:18:49pm

    I have just listened to RN's interview with Terry Platchek and I am astonished that the application of LEAN or indeed any other of the process improvement methodologies that are regularly used in industry, and indeed have been used over the past thirty years would be of sufficient novelty as to warrant coverage on the Health Report.

    Surely in Australia this cannot be the case. End to End process improvement surely is not so novel a concept as to be new to medical care in Australia. There would not be one supplier of medical equipment who would not be familiar with LEAN, Six Sigma or similar.

    If LEAN is so novel, then this is a scandal and might I suggest in need of further coverage on the Health Report as to why.

      • Mark Braidwood :

        23 Oct 2014 11:04:55am

        Hi Larry,

        I entered medicine after a career in software and IT consulting. When I entered the hospital system I was astounded at the lack of organisational maturity. I could not even start a conversation about it because nobody had the slightest idea what I was talking about it. So yes, process improvement appears to be novel in the NSW hospital system and the profession has a long way to go before it can be considered mature.