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The Man Who Declared War on Waste

by Adam G. Smith
The Man Who Declared War on Waste
Professor David Belson confers with USC Viterbi graduate students Juan Robles, left, and Ankit Bhargava on new ways to improve efficiency at St. Francis Medical Center.

David Belson once watched a CT scan technician reading a novel with a waiting room full of patients.

It wasn’t necessarily the tech’s fault – he was just following the process, waiting for someone to be sent in.

In Belson’s mind, sharpened by 10 years as a hospitals consultant in charge of destroying procedural bottlenecks, the question had to be asked: What would Toyota do?

“They would have put screaming red lights on the exam machines,” Belson said with a laugh. “Something that would let everyone see, hey, this room is idle – let’s go do something.”

Using a recent grant from the California Hospital Association, Belson, a professor in the Daniel J. Epstein Department of Industrial and Systems Engineering at the USC Viterbi School of Engineering, has borrowed lessons in lean management from Toyota – the world’s largest automaker – to improve the efficiency of more than 30 of California’s rural hospitals.

In the battle to reduce a national health care bill in excess of $2.5 trillion, eradicating waste and inefficiency may be “the low hanging fruit” of cost savings – in this case, as Belson and his students have identified: “moving patients through a hospital more quickly and efficiently.”

Over the summer, chief executive officers, nurse managers and doctors from Shasta to San Diego County immersed themselves in the study of lean management tools, including genchi genbutsu – literally “go to the place and observe.” Belson’s grant combines interactive video training through USC Viterbi’s Distance Education Network with actual site visits and implementation.

Each hospital had specific problems – the type of difficulties, it turned out, an industrial engineer like Belson was equipped to solve: reduce clinic patient post-registration wait time to no greater than 15 minutes; increase patient volume by 5 percent; and improve co-pay collection by orthopedic clinic receptionists from 10 to 25 percent.

Roni McDermott, chief clinical officer of Mendocino Coast District Hospital, had one specific problem: medication reconciliation. So, for example, if an 80-year-old woman is admitted or discharged from a hospital, there must be accurate records of her medications. What is she taking? What dosage? Who prescribed it? When did she last take it? Does the patient even understand why she’s taking the drug?

These questions are more than just administrative paperwork – they could be a matter of life and death.

“A lot of 80-year-olds don’t have a clue why they’re taking the drugs or how to answer all these questions,” McDermott said. “That means a nurse, at about $45 an hour, is taking at least an hour out of a 12-hour shift to call the pharmacy, call the primary care physician, call friends and family . . . that’s just for one admission.”

McDermott credited Belson’s training with “allowing us to hone in on the real underlying issues behind the process – he literally gets everyone involved with the process on board.”

Belson begins by observing the five or six major steps in a broken process. It’s not uncommon to see nurses assembling formations of yellow Post-it notes – “one of the greatest inventions of all time” – on a blackboard, depicting all the steps in a particular sequence: discharging a patient, getting a room ready for surgery, waiting for CT scans.

For USC Viterbi student Auroop Roy, “it’s important to see all the steps, to ask ‘What is the value of this step?’ If somebody was looking at this and paying for every step, what steps would they actually want to pay for?”

Working directly with Belson in hospitals all over Los Angeles, Roy has seen the efficiency gospel in action: “Efficiency equals lower costs, absolutely. Just as an example, Medi-Cal/Medicare has something called denial of payment. You come into an inpatient or ER and you’re given a diagnosis. Each diagnosis has a corresponding ICD coding system that says how long Medi-Cal believes that patient should be in the hospital. But say you’ve got pneumonia and you’re there five days – the longer you stay, there’s a higher probability that reimbursement won’t happen. So when you consider a CT scan that takes 72 hours to be read when maybe it should take 24 or a neuro-ICU bed that costs $12,000 a day, efficiency starts to make a big difference.”

Belson has seized upon those inefficiencies in the health care system to achieve massive productivity gains – doubling the number of daily mammograms at one Inland Empire hospital without adding new personnel or equipment. As he noted, in any other industry, even a 5 percent improvement is fantastic. “This is like shooting fish in a barrel,” Belson said. “Health care may be the most inefficient, wasteful activity in the whole country.”

Despite this, changing the culture of an entire hospital is not accomplished overnight.

Ankit Bhargava, a USC Viterbi graduate student, said: “When you try to shadow a nurse who’s been doing things a certain way for 20 years, she’s going to be wary of you. I thought it was funny – I had to remind a nurse that I had no bearing on her job. We’re just looking at the processes and learning from them.”

Belson added: “No one really sat down and designed health care. It kind of evolved over time. Doctors are not systems engineers.”

Admittedly not, but with Belson’s training, they may start to think like one.

The Man Who Declared War on Waste

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