The Sweet Spot: Where Quality Meets Efficiency

Marvell Adams

URMC’s New Director of Performance Improvement Talks about Waste, Working Lean

Pulse sat down with Marvell Adams, URMC’s director of Performance Improvement. Adams splits his time between this new task and his previous position serving as administrator for both The Living Center and Meadowbrook at the Highlands of Pittsford.

Pulse: First, congratulations on your new position! Tell us how it came about.

Adams: Thank you. The position evolved pretty naturally here at URMC. You see, while the Medical Center has enjoyed an energetic approach to performance improvement as a whole, individual efforts have been disconnected. There have been multiple project steering committees, rapid-cycle improvement teams and grassroots initiatives, but they haven’t necessarily dialogued with each other consistently, and so their goals might overlap at times, or worse, they might even compete. We were missing a dedicated coordinator – someone who would be charged with maintaining the “30,000-foot” perspective that’s essential to really grasp the needs of the organization as a whole.

Pulse: But why now? Why has building a comprehensive performance improvement arm become such a priority?

Adams: A big part of it is the environment we’re working in. Health care reform has challenged us to deliver care more safely and more affordably. These goals sometimes go hand-in-hand – like our effort to reduce readmissions, which not only lowers the cost of care but also translates into better care. The thing to remember is that none of these recent or future improvements are meant to be stop-gap measures – working “lean” is the new normal. Just the other day I was at an all-day training and Steve Goldstein said these efforts literally will transform everything we do here URMC; they’ll be one the most important things we’ll ever do for the institution. We are going have to “do more with less” consistently – and, contrary to what one might think, “leaner” care can and should mean better care

Pulse: How will you facilitate this?

Adams: A large part of my job is to create opportunities for collaboration and resource sharing. I want to identify the human talent necessary for performance improvement – in-house or outside experts who are willing to share their savvy – and then connect those experts with others who are eager to learn. For instance, take Dr. Stephen Kates, an orthopedic specialist at Highland Hospital who performs joint replacement and arthritis surgery. He’s also well-versed in performance optimization, so he dedicated an entire morning to helping Highland’s bariatric surgery team conduct a “kaizen” improvement session. The team mapped out each step of a standard bariatric surgery procedure, from patient check-in to discharge. A couple hundred sticky-notes later, they found some immediate opportunities for streamlining procedure flow and worked to implement changes on the spot. They also were able to spot several more complicated bottlenecks and have made notes to tackle them in the longer term.

Pulse: Sounds like time well spent. But, you’re not meant to supplant grassroots improvement efforts altogether, are you?

Adams: No, not at all. My position wasn’t created to be red-tape, but rather a resource. Grassroots efforts are fantastic – they remind us that performance is ultimately something we all are responsible for! But at the same time, I’d hate to see us not communicate and risk being redundant. We can share existing intelligence and resources. To help with this, we’ll also need to start using the same metrics so that we can replicate one area’s success in another. Part of working well is communicating well, right?

Pulse: Right. But let’s switch gears. There’s a large-looming question for someone in your position to consider: How do you balance efficiency improvements with quality improvements? At times they seem to be at odds.

Adams: That’s a great question. Sometimes, the goals we pursue are “competing good things.” Let me give an example. Before discharge, a patient’s medications are reviewed to ensure they are correct so that they are sent home with the right meds. This takes deliberate effort and, done thoroughly, can perhaps affect the discharge time for a patient. Juxtapose this with the performance metric of aiming for on-time patient discharges. Accurate medication reconciliation can easily compete against discharging a patient by a certain time. This type of conflict must be managed so that the big picture is kept in perspective – striking the right balance between quality improvement and performance improvement.

Pulse: How can staff help champion performance improvement?

Adams: I’ll answer by repeating one of Ghandi’s most well known quotes: “Be the change you wish to see in the world.” In other words, it is essential that we all serve as change agents for the performance issues we identify. We must be part of the solution and willing to embrace change. Additionally, some light reading wouldn’t hurt. There are some fantastic books about how strategies like visual controls (e.g., an “egg-carton” sponge caddy that helps surgeons quickly assess that all sponges have been removed after a procedure) and “5S” (an organization system focusing on sorting, setting into order, shining or cleaning, standardizing and sustaining) can keep their workgroup, lab or clinic humming smoothly. They also can attend training sessions or special seminars to keep learning. In fact, more than a dozen hospital staff from Strong and Highland recently went over to Kodak to learn more about how performance improvement strategies can help better organize workflow in our hospitals.

Pulse: It sounds like you have your work cut out for you.

Adams: I do, but I think the best part of the job will be training our in-house talent. Again, performance improvement is something we’re all responsible for – not just me, and not the consultants we tap. Ultimately, any consultants we hire will eventually leave. Once they do, we’ll need passionate and talented folks remaining on the ground to keep us on target.

Looking for a good read? Adams recommends Lean Hospitals by Mark Graban, The Nun and the Bureaucrat by Louis M. Savary and Clare Crawford-Mason, and The Toyota Way by Jeffrey K. Liker and David Meier.

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