I introduced you to value streams in the previous data. But now let's dig a little deeper and use this framework to analyze what happened to Mary. On admission to the hospital, Mary was diagnosed with a very simple disease, thrombophlebitis. Let's look at the thrombophlebitis value stream. As you can see, the management leads itself to a sequential value stream. The first step is to maintain the patient on the intravenous blood thinner Heparin to achieve a PTT of 70 to 85 or twice normal, normal being 40. In our session on team work, we will discuss the failure of even this seemingly simple value stream. Mary's PTT should have been maintained at seven to 85 and then beginning at day three, converted over to oral anticoagulation Coumadin. This conversion usually takes two to three additional days over predicted duration of hospitalization should have been five to six days, not 22. And should have required a minimum number of tests. Sequential care is simple and orderly and requires that the correct diagnosis has been made however, Mary was misdiagnosed. In reality, she had a much more complex multi-organ disease, penicillin-induced vasculitis, inflammation of her blood vessels. In retrospect, the cardiologist's decision to begin corticosteroids saved her life. Instead of a sequential value stream, Mary required what can be called an iterive work process. This more complex approach requires repeated testing to narrow the possible causes of her nerve damage frombifobitis, heart attack and high E asenithelca. Notice the repeated, circular arrows indicating repeated testing and adjusting of the diagnosis. The complexity of her disease required an expert diagnostician with over 10,000 hours of clinical experience. Why 10,000 hours? This is the time it requires to develop sophisticated pattern recognition and logical decision-making. Certainly the rotating intern, who had just begun medicine, could not fulfill this role, nor could the senior attending physician whose primary practice was outpatient management of diseases such as diabetes and hypertension diseases that usually require sequential value streams. In short, Mary was managed with an overly simple, sequential value stream by physicians who lacked the expertise to create and manage an iterative value stream. And these mistakes nearly killed her. It was only after I recruited a very experienced cardiologist with expertise in complex cases, did Mary receive the proper treatment. Patients and families beware, when care givers don't understand what's going on, be sure to request a an expert diagnostician with over 10,000 hours experience In general, this requires nine to ten years in practice managing complex cases. In Mary's case she should have been placed on a ward run by an expert diagnostician with expertise to apply an iterative value stream to diagnose and treat her illness. Once the diagnosis was made, then a sequential approach could have been used to manage her anticoagulant, corticosteroid treatment, and supportive care. As exemplified by Mary's illness, the 80/20 rule that is used by manufacturing companies applies to healthcare. 20% of the patients demand 80% of the resources. Manufacturers do not mix these complex products with their simpler ones. Instead, they slice them out and create a separate value stream. In addition, they dissect or dice the steps of their complex value stream, and continually improve the most complex steps to assure maximum efficiency and quality. As recommended by Toyota, hospitals need to slice and dice value streams that mix sequential and iterative value streams are the same services. The iterative value stream should have been sliced out and then the steps of iterative care could have been diced or separated and carefully examined. The first step is to establish the probability of each diagnosis then order the most useful test, followed by interpretation of the results. An effective test should exclude or raise to a higher probability a specific disease. In fixing health care 2.0, we will discuss this iterative decision process in more detail and introduce you to the use of Baye's Theorem. In Mary's case blood tests revealed a very high eosinophil count. Doctors call this eosinophilia. And an increase in these cells is most often to result of an allergic reaction. The finding of this value should have caused the doctors to circle back and raise the possibility of an allergic reaction as the cause of her nerve pain, rather than attributing it to a physical injury. This possibility should have encouraged a skin biopsy of her blood blisters. And the results of this biopsy would have shown inflamed blood vessels indicating vasculitis as a consequence of a severe allergic reaction. Because one of the most common medication to due such reaction is penicillin. The diagnosis a penicillin-induced vasculitis would have become a leading diagnosis and encourage the initiation of corticosteroids when delivering healthcare, we need to apply the 80/20 rule. For 80% of the cases when the diagnosis is known, we can use sequential care. And so sequential care leads itself to continual improvement by the creation of ever more efficient protocols and algorithms. The cost of managing disease requiring sequential value streams can be estimated and specific prices listed. For example, cataract surgery and coronary artery bypass. Could be offered at a fixed price, allowing patients to pick based on cost. Of course, the quality of outcome should also be an important criteria. Sub-specialty hospitals are now being created particularly in India. As a consequence, the cost for cataract surgery is significantly lower in India, as compared to the US 1,900 versus $268. In your heart hospitals use highly efficient sequential value streams that provide high quality heart care at much lower cost. The average cost for coronary artery bypass in the US $144,000 versus 5,120 in India. In other words, they provide greater value, quality divided by cost and many experts believe this should be the model for future care. But what about the 20% of cases that are complex like Mary. These complex patients can be managed on special services with highly experienced caregivers, because the diagnoses is unknown, a fixed cause for care is not possible. Ideally, an hourly rate model would work best, similar to a lawyer's hourly fees. At the present time, in most health care systems, just as in Mary's case, sequential care and interne care are mixed together and a less costively sequential care patients cross subsidise patients requiring more expensive iterative care. Isn't it time we recognise the reality of the 80 20 As you can see, Toyota has a lot to teach us. And in the next session, we will discuss other key lessons from TPS that can and should be applied to healthcare, thank you.
