Steven Spear, MIT Sloane School of Management

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter : And I ’m Margaret F linter .
Mark Masselli : Well Margaret it hasn’t been the best week for the White House in the
wake of the role out on the online insu rance marketplaces.
Margaret Flinter : Even with consultant working around the clock to fix the problems who
have plagued the Federal Health Insurance Exchange more problem still being
uncovered. Last week the system went down again, this time not the si te itself but the
part of th e system being handled by the phone company Verizon. The proble m was
swiftly identified but it’s fueling the redirect from opponents of the Health Care Law.
Mark Masselli : Health and Human S ervices S ecretary K athleen S ebelius was in the hot
seat last week coming before the House Committee , overseeing the Affordable Care
Act she is increasingly coming under fire from the GOP .
Margaret Flinter : And a growing of course from both sides of the isle considering the
frustrations wi th the online marketplace to extend that dead line for signing up beyond
March 31

st
the point at which people would have to pay the penalty and that’s being
ca lled for really considering the problem s with the frontend of the rollout.
Mark Masselli : There are also some voices reason with in all off the noise, Margaret
D emocratic Senator from West Virginia Joe Manchin said that a delay in the individual
m andate would allow for the problems to be work ed out.
Margaret Flinter : Meanwhile but we know th ere are tens of thousands of Americans
ha ve sign ed up for in surance or found they ’re qualify for coverage under the Medicaid
expansion. So, important to remind folks it i s a massive undertaking this is just the
beginning and it looks likes it just going to take s ome time to work out all t he bugs in the
system.
Mark Masselli : Our guest today is an expert in Lean system s in Health Care based on
Toyota’s efficient manufacturing platform. Steven Spear is a P rofessor at MIT and
author of the High Velocity Edge, he’s been examining how Lean Principles could work
to improve efficiencies and Health Care as well as contain cost.
Margaret Flinter : Lorry Robertson from FactC heck .org drops in with another
misrepresent ed fact about health policy but no matter what the topi c , you can hear all of
our shows by Googling CHC R adio.
Mark Masselli : And as always if you have co m ments please email us at chc radio.com
or find us on Facebook or Twitter because w e’d love to hear from you.

Margaret Flinter : Now we ’ll get to our inter view with Steve Spear in just a moment.

Mark Masselli : But first here is our producer Marianne O'Hare with this week’s Headline
News .

(Music )

Marianne O'Hare : I’m Marianne O’Hare with these H ealth C are H eadlines. The f allout
continues over the role o ut of the online insurance market places last week another
g litch was added to the problem p lagued role out, Verizon the phone company
responsible for the link from the sates as well as the Federal Exchanges for the ever
important data h ub that went down s hutting down the Federal Exchange for a while and
hampering state ex changes relying on the link. W hile the Administration still insist
problem should be work ed out by November Health and H uman S ervices S ecretary
K athleen S ebelius was being barrage with c r iticism mostly from GOP circles . She
appear before the House Committee overseeing the Health Care Law and insist ed
everything was being done to correct the problems be setting the online insurance
marketplaces .

Meanwhile President Obama took the Health C are L aw s message to Boston last week
in the state that past the first man date to carry insurance in the nation . The President’s
speaking to positive impacts when an entire population carries health insurance
coverage as they are Massachusetts better over all public house.

Meanwhile Vermont’s Insurance Exchanges are up and running but that state has loftier
goals a state is on track to have a fully operational state health plan by 2017 a s the first
in the nation state funded Medicare for all approach Vermo nt has traditionally been at
the for e front to providing coverage for all of its residen t s e sp ecially those most
vulnerable . I’m Marianne O'Hare , with these Health Care H eadline s .

(Music )

Mark Masselli : We are speaking today with Steven J . Spear a PhD S enior lecture at the
Sloan S chool of M anagement at MIT, and s enior fellow at the I nstitute for H ealth C are
I mprov ement . Dr. Spear has written numer ous critically acclaimed books and articles
on the application of L ean S ystems to I mprove M arket S uccess , in cluding in Health
Care . Among them decoding the DNA of the Toyota production system and the high
velocity edge as well as the award - winning Harvard Business review article Fixing
Health Care From The Inside. Dr. Spear earn ed his master’s in e ngineering a t MIT and
his PhD in Business from Harvard. Dr. Spear , welcome to C onversation s on H ealth
C are.

Dr. Spear : Oh thanks for having me.

Mark Masselli : Steven , you are know n as a n expert in the L ean S ystem s created by
Toyota back in the 1950s to capture th e Automobile market from the industry l eaders

like Ford and GM and originally it was called “ Just In Time Production ” but Lean is -- a
lot of the young Japanese company to surpass the big three au to makers in creating
c ars that were more affordable but muc h higher in a quality and re liability as w ell . It’s a
model that’s been replicated in varying digress of success in other industries , it’s come
late to health care . Can you tell us a little bit about the essential elements of L ean and
how you see it r oll ing out in the health care industry ?

Dr. Spear: So, when we go ba ck, look at Toyota’s expands in the late 1950s when they
actually first tried the US market. They showed up with an embezzling car and they
were hardly inefficient in making it. But, what happens is that from the late 1 950 s till the
early 1960 s Toyota went from being one eighth as prod uctive a s its competitors to
equally productive by the late 1960s there were twice as productive and when they
came to the US market in the 1970s they were n ot only twice as productive but twice as
productive making better product . And then it just snowballed in terms of speed of
improvements a t speed so Toyota started a dramatically compress ed the time it took to
re fresh models in a major way compress ed dram atically with the time it took to
introduce new models introduce new brand s like Lexus and Scion and then introduce
new technology like that in the hyb rid drive . You know first in the Prius but now across
21 different platform s .

Margaret Flinter : Steven , you recently participate d in a study conducted by the
Instituted for Health Technology Transformation that was entitle d the L ean IT M aking
H ealth C are More Efficient to expl oring the potential for Lean princip les to transform
Health Care to be more cost effective and more efficient . But the focus was on the
need to apply a L ean approach to help information systems as an essential starting
point , so why is that the essential starting point , w hy not at the b e d si de or in the lab?

Dr. Spear: So, what we s ee , when we look at these folks climb from not very good to
very good to mind bogglingly great is w e see that they -- they have this very fast highly
compress relentless learning cycle s, what’s essential to any learning cycle is the ability
to first know w hat you think is going to happen, detect the abnormality against what you
t hought was normal what you predicted . And then quickly look back and understand the
source of that that abnormality. So the great organizations not only have sound well -
designed t houghtfully placed organizational structures , they have this over way of
incredibly robust dynamic s for the purpose of control and im prove ment . So as far as IT
goes, what you ’d find in many organization and certainly health care the workforce is
mobile , t he work is highly varied is that a lot of these organization s lack in a sense the
nervous system to know what’s going on currently h ow -- what is going on differs from
what’s expect ed and where resources need to be devoted both immediately and over
the lon ger term to built the robust as to health in the resiliency of the system. So, why
worr y about the IT ? S imultaneously and not also worrying about the dynamic s and the
dynamic s are inform ed by information, if you ’re not worrying about the dynamics you’re
only get part of the way towards the right answer.

Mark Masselli : Steve and you have compare d the L ean approach to the scientific
methods w here workers are trying to see a problem and do a root cause analysis, tr y a

solution and incorporate that system i nto the new cycle in it. You see enough to pull the
cor d on the assembly line to fix a problem as soon as it’s discovered but it’s much
harder to do it with the health care workflow, I know we had Dr. Peter Pronovost a while
ago and he was talking about b eing in London trying to teach the nurses to stop a world
renown surgeon w e they saw something was wrong sort of a cultural problem that one
runs into . So tell us what you have learn ed f rom your earlier experiences about
a pplying Lean health institution s and what are the essential components of L ean
principl es in Health?

Dr. Spear: Yes, what you describe d was, the behavior al shift from -- not even recogniz e
and dealing with an abnormality. To recognize that the abnormality is something which
should trig ger a meaning ful response in t erms of con tainments, correction and
mitigation to prevent recurrence and so this reference had made to Dr . Pronovost gets
back to the core behavioral and showed having to teach people that, when they observe
an abnormality it ’s something t o be respect ed and respect ed through response . So for
what it’s worth and as in how clinicians are trained they are tr ained to trea t, the
biological system at the core of their work the patient . So medical scientist made huge
advances in de fining, what normal is, you know, we ll be yond the 98.6 and 120 over 70
and also the scientist and technologi st have made extraordinary advances, in creating
the monitoring systems and so , what we are talking about here in terms of building the
resiliency t he robust as to how the organizations which we’re trying to buil d the
resiliency the health of the patients at the core . To teach them also to get into th is habit
of defining normal for the purpose of detecting a bnormal and then swarming on the
abnormal b oth to contain it before it has an infectious spread like experience . But also
to investigate the source of abnormal so you can treat it to prevent recurrence.

Margaret Flinter : Steven, in your book the high velocity edge, you talk ed about how
certain m arket leaders, I think you refer to them as breathtakingly good before. So that
high velocity organizations have the certain characteristics that really set them apart
from the competition and that those charac teristics allow for this continuous
improveme nt of the individual parts and the process as well . Which is a complicate
sentence for people to understand so, may be you could sh are with our listeners again
thinking about health care . What are these high velocity principles, where do you see
them work ing successfully in health care?

Dr. Spears : So w e have to keep coming back to this notion that, success is rooted in
the mechanics and the behaviors of learning and discovery, with a very few and wear
exceptions . T he only thing we can do in terms of be ating in the comp e ti ti on is figure out
how to move faster than they do towards figuring out what the market place really want s
in this case what our patients really value . And figure out how to deliver that value more
effectively more efficiently than som ebody else, so that’s the basic concept .

Now if you think about what a clinician does day to day , they have a patient come in,
doesn’t shows up because I don’t feel well and the clinician then says all right let’s have
a talk about that what is your histo ry I’m going to do an examination and all of that is to
arrived it and understanding of the patient and determined what’s normal was that went

off so that the abnormality which present a symptoms can be understand down to a
diagnos ed c ause the clinician th en take the next step and saying well now that I have
some sense of what is causing you r symptoms the next step is to develop a treatment
plan , which bio logical ex periences and so on and so forth, is likely to offset the causes
or correct the causes so the se symptoms will disappear and that establishes a
prediction of a target of what the result of treatment time will be. Then the physician --
the clinician comes back and recycle s and says, w ell w hat was it about how I did the
examination and the work of t hat got me to a result different than I predict ed. And then
so you get that cy cle of discipline scientific thinking staring with symptoms and trying to
get to wards cure, like you discover there are this common themes and the common
themes are exactly livi ng to the behavior that w e ll discipline d, affective efficient , skill
clinician apply every day.

Mark Masselli : We are speaking today with Steven J . S pear a PhD Senior Lecture at
the Sloan School of M anagement at M IT and senior fellow the Institute for He alth Care
Improvement. Dr. Spear has written numerous award - winning books and articles on the
application of L ean systems to improve market successes including the Harvard
business review article fixing health care from the inside . Y ou know , Steven , I wa nted
to sort of probe you a little on -- we have been talking a little bit about organizations and
structures but we also have a lot of primary care providers at smaller practices th at are
listening in -- and I wonder how Lean has s caled down to those offi ces you know I think
about the hospital situation really bad things can happen that a re pretty dramatic. But in
primary care settings things happen in a slow way but they ’re really bad someone’s no t
watching a h ypertension what do y ou see out there in the market places in terms of
L ean that’s can be applied at a small er organization al level.

Dr. Spears : A ctually some of our most dr amatic success es has been in that primary
care inbuilt toward the setting. And to give you some quick ones , when we first ha d a --
started in primary care we’ve worked with one practice that took – and so they started
with something simple which was the (13:47 Inaudible ) flu shot clinic. Day one there
was inoculating with say five, six patient s an hour, by the second and third day the y
were up to 30 patients an hour and the joke was they ’ve gotten so fast that providing
this inoculation that they really should have move from their office outside the y just have
to drive through inoculation clinic this is in up in Rivera , towards the Boston in front of
the beach and it would have been a very, very cynic place, you know, just stick your
arm off the window then they itchy with the needle, you know, where are you going
you’re done and, you know, 15 - 20 seconds and what they are able t o do is take a
situation where for your first appointment let’s say you’re a new patient, you might have
to wait weeks or a moths, they got that down to day s , and for a patient who’s showing
up for a follow up is just no t feeling well or want to see the do ctor, it -- they took what
was call and make an appointment and you ’re going t o wait hours a days, when you
walked in , you sign in and initially went to the exam r oom with the medical assistant as
opposed to walk and wait on line, sig n in and wait in the w ait ing area .

So they added enormously to the capacity of their practice without adding any people
and it wasn’t that they added capacity b y working hard er, they added capacity b y having

a much, much better sense of the ir process es and how to make them mor e robust and
resilient. And at the same time reducing the overburden on staff, and moving from
primary care to specialty care just for a moment we did, work with an orthopedics
practices Brigham Foster Hospital here in the Boston area, they were a t this - - we ’re
going to declare what we think is necessary to get a patient in and out of the practice for
examination purposes, we ’re going to be very attentive to w hat’s going right and in
particular what’s going wrong. And then we’ll incorporate what we ’ve le arn ed on the
next cycle . And so they got into the winter with the expect to be high point in -- they a re
heading the end of a session and everyone’s says my goodness it’s been so slow you
know, we are so surprise d that we are not experiencing the seasonal surgeon th e man
w e normally do and someone discovered they had handle s 50% more patient s that day,
then a comparable day the previous year . So to your question does this work in primary
care and -- absolutely and again it gets back to the basic premise h ere, e xceptionalism
comes from exceptional patient discipline in learning cycle.

Margaret Flinter : Well Steven the other big see change that’s going on obviously life is
the enrollment phase of the A ffordable Care Act t hat certainly holds the promise to
address one of our health care systems most clearing problems which is the in ability of
tens of millions of people to afford health insurance and h ave coverage. I’ m c urious as
you think about the A ffordable Care Act what aspects best reflect your ideas of a pplying
Lean principles to improving not only the cost of care about the quality of cares as well.

Dr. Spear: The A ffordable C are A ct at least as it a spouse is a mean s to provide people
without resources or resources t o access care . And the notion t hat we have a s ociety
which more people rather than fewer can access health care we have to agree is the
mor al ethical derived thing. What we have currently with health care are providers ,
w here the value generated relative to the resources consume d is re ally poor, everyone
is l istening to this , I know listening you know looking in a nice radio t hey got listening
perhaps through a computer , phone, or whatever else. And all of those devices we
have the regular experience that the thing we buy today we prob ably pay no more today
than we did for the previous version, the thing we buy today has way more functionality
at a much more -- way more functionality, much greater availability those thing we
bought two, three, four, five years ago and it maybe the same price or less. And that
experience we have with electronic s and consumer devices it’s true with industrial
devices it’s true with transportation, t rue with food, it’s true with lodging entertainment.

S o, we have this problem in health care where unlike e very other sector innovation
doesn’t improve quality, improve availability while still driving down you in the cost so,
you know, how does this apply into the Affordable Care Act. We saw this basic problem
that the folks who provide care have to do better in terms of managing the delivery of
care that they have historically, in terms of engaging , this learning dynamo. So, that not
only they providing more care to more people because they’re getting paid more in
(18:08 Inaudible ) but they’re providing more Affordable Care and more people of higher
quality is that they’ve got this learning dynamo going which whatever they are doing
today informs tomorrow how to do, what they are doing better.

Mark Masselli : You know you have talked a lot about how change h appens in an
organizational structure and it clearly requires the leadership of a Chief Medical Officer,
Chief Executive Officer. But, you know I was also thinking you know, we have been
engage d in using Dartmouth’s Clinical Micro Systems and GE’s changes acceleration
process in, we also understand that you need the frontline people engage d if you’re
going to really get meaning ful change . So there is a lot new ones in this talk to us about
it from the organizational level both from the top right down to t he frontline of what that
system needs to be a vibrant learning renewing system.

Dr. Spear: Yes, there is no substitute for the senior leader setting the tones to what the
behaviors and the values of the organization are . So at the end of the day the se nior
leader says how many patients do we treat today . The answer will be a number another
hand is if the end of the day the leader says h ow many patients do we treat today a nd
the course of treating them what g ot in your way, and the senior leader expound s upon
that, that question of what got in your way and s o well the things that got in your way,
wh y do you think they got in your way and you need help investigating, examining,
diagnosing as to why they go t in your way, it changes the conversation even fu rther,
what got in your way? W hy did it get your way ? What can we do differently tomorrow
and how can I be helpful to bring those changes into place that create s a much different
dynamic s than how many patients do we did deal with today, how many people did we
treat today?

Encourages you towards driving towards more and more numbers not necessarily good
or bad experiences, the second one encourage s you to celebrate the successes but, be
thoughtful about the obstacles and difficulties to trigger for that self reflective self
corrective learning cycle it can ’t be senior leader alone because the question of what
got in your way can only be answered by those who are doi ng the direct work o f the
organization because it’s in their w ay, that the obstacles got t he folks working on this
frontline are the n umber standings of the organization s say oh it’s hot here, oh that was
short but that was painful. And it has to travel up the nervous system the senior leaders
to help encourage the sensing, then it’s the senio r leaders who can actually authorize
and enable the actuation against that sensing in that and that synthesis, in fact there’s a
top down and bottom up occurring simultaneously because what ’s occurring t op down,
once occurring bottom up both if necessary n either or sufficient.

Margaret Flinter : Steven, we ’ re very passionate in our organization about training the
next generations of people who will, deliver care and organize care and the accurate
statement to sat th at we’re focused on train them to a high performance model of health
care and primary care and we find ourselves really starting at ground zero in training
people in the tech niques and methods and schooling if you will of quality improvement
of L ean and of other techniques. What are your thought s about the best ways at which
you train people in some of this area that we have been discussing today?

Dr. Spear : It strikes me that both Engineers and Clinician s ha d a similar starti ng point.
Which was -- the re were science and technology which was b eing develop ed w ithin a
profession . And then in order to be confident as professionally h ad a masters at the

science and technology with in your field, but at some point there was a stiffing where
even if you are exceptional with in your profession that was n’t sufficient to get a good
result s and a simple reason wa y is that good result s depended on the ch oreograph
synchronize contribution as many professional s across many disciplines toward some
comm on propose, I mean cars for example each ones were purely i ron steel plate , a
mechanical devices now that the iron steel mechanical is a m ere fractions of a total
value of the car, it w as a long ago that the electronics became the majority value add on
the car and now you could probably make an argument that the s oftware con trols
actually sup er see the electronic and super see the mechanics in terms of the total
value of the product. What happen in engineering is that from very really on engineers
had train ed very deeply within their particle discipline.

But, eve n at the under graduate level engineer gets projects which are a cross
disciplinary and th ere’s a socialization for an engineer to understand that the expression
of their professional potential is in services to the largest system they are trying to
design and the larger system they are trying to operate and that, the better and better
they get the larger at the system in which they can make a contribution . Health Care
my observation experiences and narratives like, health care professional share is that
th ey are trained within their dis cipline but, they are really trained either for the
socialization p iece or the professional expression piece to understand that their
potential is express in services to a system much larger to fend themselves. So, th ere’s
s till this , what is now a widely outdated cliché of this other health care profession
somehow orbiting around the physician as o ppose to physician being a high ly skilled
profession w ho’s working in service to a sy s tem much larger than himself or herself.
W hen we ed ucate or health care professional, we should really be cognizant of their
success as professional s will be as part of team much, much larger than themselves,
we should start training them early on, on how to be part of a system and not train them
and get t hem to somehow expected they are still this independent self standing
professional s may have been the case 30 and 4 0 years ago.

Mark Masselli : We have been speaking today with Steven J . Spear. PhD Senior
Lecturer at the Sloan School of Managemen t at M IT and senior fellow with Institute for
Health Care Improvement, you access the recent report L ean IT Making Health Care
More Efficient at iHelathTrend.com and you can find out more about Steven Spear’s
work by visiting his b lo g the high veloci ty edg e . Steven , t hank you so much for joining
us at our Conversations o n Health Care .

Dr. Spear : Oh you’re quite welcome and thank you so much for the invitation.

(Music )

Mark Masselli : At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy. Lori
Robertson is an award - winning journalist and managing editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for voters that aim to reduce the level of
deception in US politics. Lori, what have you got for us this week?

Lori Robertson : Well several r eaders have ask ed us whether the A ffordable C are A ct
restrict insurance coverage of mammography the answer is n o in fact the l aw requires
insurers in to cover mammogram s without any cost sharing every one to two years for
women starting a t age 40, for women with Medicare the law increase coverage
Medicare now fully paid for yearly mammogram s starting at age 40. Despite what some
our r eaders may have heard there is no cu toff or upper age limit for mammograms to be
cover ed through M edicare we call the American C ancer S ociety the nonprofit Medicare
right center and the American geriatric society and no ne had heard of any issues o r
complains of seniors be ing denied mammogram s.

So, where d oes this false rumor come from? At least some of the claims are
misinterpretations of 2009 recommendation from the US preven tive services task force.
The task force that they volunteer panel with primary care physicians and preventive
medi cine experts, they ma de the controversial recommendation that by any old
mammography screening should begin at age 50. For women younger than 50, the
panel said the decision to have a mammogram was an individual choice for women 75
and older the panel sai d evidence wasn’t available to determine benefits versus harms ,
the panel did not say that women under 50 or over 50 shouldn’t get mammogram s at all.

The 2009 recommendations were rejected by some cancer groups and they were
specifically rejected by the A ffordable Care A ct which again require s full coverage o f
mammograms as a standard prevented benefit, starting at age 40 and that’s my
F act C heck for this week. I am Lor i Rober t son Managing E ditor of F act C hek.org.

Margaret Flinter : FactCheck.org is commit ted to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact, that you would like checked, email us at
www.chcradio.com. We will have FactCh eck.org's Lori Robertson check it out for you
here on Conversations on Health Care.

Margaret Flinter : Each week Conversations highlight s a bright idea about how to make
wellness a part of our communities and to everyday lives.

Smoking bans across the c ountry have y ield a countless health benefits emirate ways
reducing smoking related illness and death. And while smoking in most building s and
public establishments has been banned across the country for years it’s still a
ubiquitous practice in most of t he nation ’ s casinos subjecting employees and patient s of
this establishment s to prolong the secondhand smoke exposure . The S tate of Colorado
recently pass ed a banned on smoking in the state ’ s c asinos and the result s have been
dramatic, once smoking was ba nned the number of emergency a mbulance calls drop by
20%. Dr. Stanton Glantz, Director of the Center for Tobacco Control Research and
Education at the University of California San Francisco says it’s really a pretty simple
equation, long term exp osure to secondhand smoke increases the risk of the
development of blood clots that can block arteries causing an attack.

Dr. Stanton Glantz : And even a few minutes o r secondhand smoke exposure is enough
to make your blood platelets get stickier and when that hap pe ns they stick together and
they’re more likely to form a blood clot and if that blood clot lodges in an artery in your
heart, it causes a heart attack. And also the sticky pl atelets tear up the lining of the
arteries so, you can have people who never sm oke in their live but had a b a d family
history onward and increase r isk of he art attack who w alked into a smok y casino and
the short term exposure in that casino or any other smoky environment can actually
trigger out heart attack.

Margaret Flinter : Exp o sure to cigarette smoking also trigger ed other adverse events
like stroke , asthma attacks and COPD flare ups. The American H eart Association has
applauded the first of its kind study supporting the smoking banned in casino s and
hope s th at operators of cas inos around the country take note.

Dr. Stanton Glantz : The clear implication of this work is continuing to permit smoking in
casinos and other environment for that matter sending people to the hospital and it’s not
doing it next month or next years or fi ve year f rom now it’s doing it right now and 20%
change in the number of ambulance calls you know, I mean that’s very substantial.

Margaret Flinter : A smoking banned in casinos populated by thousands of people
eliminating secondhand smoke exposure to tho se people and significantly reducing
smoking w relate medical emergencies now that a bright idea.

Margaret Flinter : This is conversations on Health care I Margaret F linter .

Mark Masselli: And I’m Mark Masselli , peace and health .

(Music )

Conversations on Health Care broadcast from the campus on WESU at Wesleyan
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Center .