Dr. Frederick Southwick: safer care through multidisciplinary teamwork and lean methodologies
Dr. Frederick Southwick is a professor of medicine at University of Florida, where he was previously the Chief of Infectious Diseases. An award winning teacher with over 30 years of clinical practice, Dr. Southwick has personally experienced the consequences of the flawed healthcare system and works to analyze the systemic process challenges of delivering care in hospitals and clinics.
What do you worry about the most when it comes to delivering safe patient care? Where do you see the biggest room for improvement?
Poor coordination of care and limited communication are huge problems in the delivery of health care. The Joint Commission has found that in 2/3rds of sentinel events (errors that lead to death or serious patient injury or had the potential to cause these outcomes) were at least in part the consequence of poor communication. Care is extremely fragmented because of the many subspecialists required to manage the ever-increasing number of therapies. Patient care is further fragmented by the need for multiple patient handoffs because of the 80-hour work rule, as well as the hospitalists’ routine of rotating every 7 days. Communication can be improved by using established communication protocols such as IPASS, SOAP and SBAR, and by teaching and practicing effective multidisciplinary teamwork.
What are some of the best practices or processes you think hospitals can leverage from other industries? How can we translate them to patient care?
The industrial model that has had the most consistent and dramatic effects on improving the quality, efficiency, effectiveness, and safety of patient care is Toyota Production System or Lean. The tools that have been effectively translated to health care include value stream and process mapping, rapid improvement events, error proofing, visual controls, and just-in-time supply chains. This system has been adopted by Virginia Mason Medical Center, Seattle Children’s Hospital, and Denver Health, and has reduced medical errors and patient mortality, improved adherence to scientifically established patient management plans, and improved patient satisfaction while reducing the costs of patient care at the same time.
For hospitals who have implemented lean or six sigma processes to improve operational efficiency, what do you think is key in making sure the impact of these interventions is sustained?
These system-wide initiatives require alignment at all levels. The CEO of the health system must be a champion and be actively involved in overcoming the daily impediments and rewarding the successes associated with implementing this system. Everyone on the front lines must become actively involved in creating and continually improving standardized work.
In addition, every hospital system must train a critical mass of experts in the Lean processes. Denver Health trained one expert for every 2 beds in their hospital. Their Lean Black Belt trainees serve as champions and as experts to guide improvement efforts. There must also be a coordination of improvement efforts by a multidisciplinary steering committee consisting of administrators, physician leaders, nurse leaders, and experts in management engineering. This committee should set the annual priorities guided by value stream mapping and performance data, and serve to integrate the individual improvements to create a fully coordinated health system.
The implementation of Lean requires a prolonged commitment of 7–10 years. Such long-term commitment does not fit with the 3–5-year business cycle, and performance incentives of standard CEO contracts. Therefore, the implementation of Lean is only possible if the hospital system’s Board of Directors understands the time requirements of implementing this system. The carrot at the end of the deliberate implementation of Lean: a 4X increase in productivity accompanied by 99% reduction in errors. Shouldn’t every hospital system embrace Lean?
Where do you think current technology falls short in helping hospitals and medical professionals deliver safe care?
One of the most inefficient systems in modern health care is the electronic record. Physicians, nurses, and other frontline providers spend an inordinate percentage of their time entering data in electronic records. Many have assumed that the introduction of electronic records would improve the coordination of care and reduce medical errors. However, to date these expectations have not been fulfilled. Use of smart phones and voice recognition software would allow immediate data entry during the face to face encounters and improve the efficiency of data entry. Text messaging and group virtual meetings using the internet have the potential to improve the coordination of care and enhance teamwork.
What are some of the initiatives you are currently working on? What is the impacts you are hoping to achieve?
I continue to encourage the use of athletic principles to improve multidisciplinary teamwork. Nearly everyone working in health care has either played on an athletic team or is a fan of an athletic team. Therefore, virtually everyone in health care has a rich understanding of teamwork, and with a little additional training they can apply these athletic-based skills to the treatment of patients. We previously implemented a program that encouraged the adoption of playbooks, understanding who was passing and receiving (customer-supplier relationships) and adopting a game film mentality (always asking about what went well and what could be improved?). The program resulted in a 20% reduction in patient length of stay and a 30% reduction in patient 30-day readmissions, as well as a marked increase in nursing job satisfaction, and the agreement by all participants that work rounds were more efficient. We are about to study how implementation of this rounding system effects participants’ attitudes toward teamwork. Do they learn by doing, and progressively increase their understanding and appreciation of effective teamwork?
In addition, I will soon be releasing a new course on the Massive Open Online Course (MOOC) platform Coursera entitled “Fixing Healthcare Delivery: Advanced Lean.” With my last course reaching 22,000 students from 150 countries, students will learn the basic principles of Lean or Toyota Production System and gain the skills to apply the tools used by Virginia Mason, Seattle Children’s Hospital, and Denver Health to continually improve the performance of their healthcare delivery systems. My hope is that a large cohort of health care providers and administrators will embrace this comprehensive approach to delivery system integration and use their new skills to continually improve the quality of patient care to save lives throughout the world.
