Ed Kinchley

Public hospitals are too Lean



The San Francisco Department of Public Health is paying Rona Consulting Group, an out-of-state consulting firm, $1.3 million of taxpayer dollars to implement a program called “Lean,” allegedly to improve patient services. The “Lean” program is based on the Japanese Toyota automobile production model.

Hospital quality improvement schemes such as the Lean promise decreased waiting times, improved communication, more satisfied patients, and safer care. Quality care should also decrease the incidence of hospital-acquired conditions so that patients leave the hospital without getting new infections, falling, or getting pressure ulcers such as “bed sores.”

Hospital administrators are telling health care workers and patients that Lean will achieve these widely shared goals. Yet despite years of efforts, there is no evidence that it works, and growing concern that resources must be increased rather than prescribing the Lean diet to an already starving public health infrastructure.

Health care should be based on the best available science — not corporate sales. The Lean program encourages the hospital staff to consider its workplace as a factory shop floor, and to consider their patients and work as a product. The competition for well-insured patients and improved satisfaction for reimbursement has caused hospital administrators and Lean consultants to propose surgical clinics that resemble Nordstrom or the Hyatt Regency.

Lean’s management methodology, based on Toyota’s selected Japanese words, is used to mystify and dazzle. Instead of the pharmacy window, we are told that all staff must go to the “gemba,” which the consultants (not the dictionary) say is Japanese for “where the work happens.” Many highly paid hospital administrators and even clinical staff have been re-named as “kaizen promotion office” leaders. Those who have completed advanced training are awarded a “black belt.” The use of Japanese terms is clearly meant to add a sense of authority.

Evidence-based medicine and nursing have been examining high-quality studies of the effectiveness of improvement schemes such as Lean. According to “Guiding Inpatient Quality Improvement: A Systematic Review of Lean” (The Joint Commission, 2012), “the true impact of these approaches is difficult to judge, given that the lack of rigorous evaluation or clearly sustained improvements provides little evidence supporting broad adoption.” This leads to very expensive, wishful thinking. When consultants are paid from $4,700 to $25,000 a day from public funds intended to construct a seismically sound hospital (see “Toyota work methods applied at General Hospital” San Francisco Bay Guardian, May 7, 2014) it seems important to consider what randomized controlled trials tell us. The taxpayers have a right to know what to expect from this scheme, but there are no controlled scientific studies to tell us.

Despite more than 10 years of multiple published studies, very few consulting firms even report statistics. Those that do show weak evidence of effectiveness, and none show sustained improvement. If Lean were a medication, it would never receive approval from the Food and Drug Administration, as we don’t know if it helps or hurts the care of patients. As it is, hospitals are performing a single-group intervention study without ethical approval or consent from the workers and the patients.

Hospitals should be providing their patients with the best care, not the cheapest. Even if Lean didn’t come with a price tag to taxpayers ranging in millions of dollars for consultants to do the work that administrators should be doing, the underlying notion of speed is dangerous in health care. Public health patients are even more vulnerable with increased prevalence of poverty-related co-morbidities, from diabetes to tuberculosis. If there were a way to more quickly cure our population of its many ills, we would embrace Lean.

Nobody likes to wait around, but the human connection between caregiver and patient takes time. Efficiency should not be valued over safety. Furthermore, many patients would be unhappy to learn that they are being viewed as inanimate products on an assembly line. Nor does it please health workers to think of themselves as robots.

Hospital safety under Lean is being modeled after the same automobile corporation that was just forced to pay $1.2 billion for concealing safety defects (“Toyota Is Fined $1.2 Billion for Concealing Safety Defects” New York Times, March 19, 2014). The safety defects were implicated in unintended acceleration of some Toyota vehicles that led to injury and death. Speed was certainly not helpful in that situation. Perhaps DPH should critically examine Lean before prescribing a diet to our vulnerable safety-net patients. Maybe we need more, not faster, health care workers.

Ed Kinchley has worked for DPH for 30 years, after spending nine years in Japan.

Don’t privatize public safety


Four weeks ago, surgeon Dimitry Nikitin walked out of Florida’s Orlando Regional Medical Center to his car and was shot dead by a disgruntled patient who then turned his gun on himself and committed suicide. Last September, a doctor at Baltimore’s Johns Hopkins was shot and killed by a patient distraught over his mother’s terminal diagnosis.

There is an epidemic of violence in America’s health care facilities. Many of the scenarios are familiar — the news is full of stories of combatants in gang fights following wounded rivals into hospital emergency rooms to finish them off. But the full depth of the problem is largely unreported and extends to hospital wards, clinics, and long-term care facilities

A recent report from the U.S. Department of Labor based on 2009 statistics says health care providers rank third in the likelihood of being assaulted on the job — just behind police and correctional officers. In 2009, there were 38 assaults per 10,000 nurses aides.

Despite this troubling trend, the San Francisco Department of Public Health is asking the Board of Supervisors to approve its proposal to replace institutional police officers in some public health facilities with low-paid private security guards.

Here are two reasons this is a profoundly bad idea.

1. Health care is a stressful environment and growing more stressful every day.

As the providers of last resort, public hospitals and clinics often face a perfect storm of patients who are involved in violence, alcohol and drug abuse, or are suffering from untreated mental illness. But even outside emergency wards, health care workers must work up-close with patients and family members pushed to the breaking point by an overburdened delivery system.

As health care costs spiral, public health budgets shrink and access to high quality care dwindles, many hospitals and clinics are reporting assaults by patients and family members upset by long lines, half-day waits, and unaffordable care.

According to a September report by CNN on rising violence in health care facilities, violence caused by patients’ frustration with health care services is on the rise.

“People are just tired of waiting, or they are just angry that they’re not getting the care they feel is acceptable,” nurse Rita Anderson told CNN. “Instead of saying something, their response is yelling, hitting, screaming, and spitting.”

2. Well-screened and trained security officers reduce health care violence.

According to a study on reducing violence in hospitals by the National Crime Prevention Council, three top strategies for keeping health care facilities safe include reducing patient wait-times through well-organized and managed patient processing; controlling facilities through locked wards, staff ID badges, and security cameras; and hiring carefully selected and well-trained security personnel.

Currently, San Francisco’s hospitals and health care facilities are protected by highly trained San Francisco Sheriff’s deputies and institutional police officers. The Department of Public Health wants to replace some of these officers with private security guards.

But the private security industry is notoriously bad at screening recruits and plagued with turnover, in part because of low salaries. As a result, the use of private security creates unsafe working conditions for employees who deal with difficult or violent patients, such as those in San Francisco’s psychiatric emergency wards.

Unlike institutional police officers, private security guards cannot make arrests. Instead, they must involve the San Francisco Police Department, accumulating costs that quickly defeat the budget savings of using low-paid private guards to do work that should be done by highly trained officers.

Everyone who uses San Francisco’s public health system should contact the San Francisco Board of Supervisors and ask them to make the right choice to keep our hospitals, clinics, and long-term care facilities safe.

Ed Kinchley is an emergency room social worker at San Francisco General Hospital.


The decimation of public health


OPINION Crisis seems omnipresent these days.: it’s hard to find a newspaper that doesn’t carry the word in a headline at the top of the business section, or even on page 1. But a liquidity crisis seems a lot less solid when compared to the kind of crises faced by people in a society without health services.

San Francisco has developed a strong mental-health infrastructure, with respect for mental health consumers’ viewpoints and rights.

As an alternative to confinement — a coercive practice that can alienate patients — this city has acute diversion units: houses that serve as recovery centers for people in psychiatric crises. Psychiatrists manage medication, and nurse practitioners conduct health screenings, as you’d expect, but this is just the beginning of a broader approach to mental health. Residents work with professionals to develop their own treatment plans. They meet for discussion groups and trainings on topics that affect their ongoing mental health, like relapse prevention, symptom management, and medication education.

Participants help cook and clean to prepare themselves for independent living. Every year, 1,400 San Franciscans use these units.

We also have created culturally competent services. In immigrant neighborhoods and at San Francisco General Hospital, we have services in Spanish and Asian and Pacific Islander languages — services that help prevent the problems that can occur when native-language support is unavailable.

And the city has embarked on a grand experiment: Healthy San Francisco is designed to provide health care — before things get to crisis level — for any city resident who lacks insurance.

Unfortunately the crises have collided. These programs, along with dozens of others, are slated for closure next month as part of the city’s emergency rebudgeting response to our economic crisis. Half our acute diversion units will close. Hundreds of monolingual San Franciscans will lose services in Chinatown and the Richmond District, and General Hospital may lose half the Asian languages with which it can communicate with mental health consumers. New Leaf will cut therapy for 50 gay clients with combined mental health and addictive disorders. The sexual assault trauma recovery center will close.

Healthy San Francisco will be gutted. Staffing has not increased sufficiently to provide high quality care for all patients, and SF General will downgrade service by replacing skilled nursing jobs with less-skilled positions. Some RNs will be eliminated, LVNs will be replaced, certified staff will be replaced by noncertified staff, and clerks with medical training will be reduced to clerical work.

These are just examples. Cuts were made so hastily that nobody yet understands their full extent. But budgets — for all those digits and decimals that smack of hard economic truth — exist in the nebulous apparition of What May Be. And what may be, may yet be changed.

This month, the Board of Supervisors has the opportunity to change this future, and to protect the health and, in some cases, the lives of thousands of San Franciscans. Public health will receive cuts: that’s a sad truth of a faltering economy. But these cuts need be neither as numerous nor as deep as the current plan.

By reallocating funding from less essential programs to our most vital services, and by giving San Franciscans the option to vote on new revenue in June, the supervisors can respect the priorities of a city that cares about the well-being of its ill, its injured, and its uninsured.

Alysabeth Alexander works with La Voz Latina. Jennifer Friedenbach works with the Coalition, and SEIU Local 1021 activist Ed Kinchley is a member of the Coalition to Save Public Health.