Dr. David Kashmer, MD, MBA, FACS is a Surgeon and Health Care Quality Strategist. He is a Fellow of the American College of Surgeons and holds a Master Black Belt Certification in Lean/Six Sigma. Dr. Kashmer is innovating the path to quality improvement in health care through use of statistical process control techniques.
In this interview Dr. Kashmer talks with Bill Kopatich about innovations that are making large improvements in the quality of health care delivery.
Bill: Dr. Kashmer, thanks for joining me today to talk about some advances that are being made in the quality of health care delivery through methods that have not been so commonly used in the medical industry.
Dr. Kashmer: It’s a pleasure to be talking with you today, Bill.
Bill: Dr. Kashmer, what led you to enter the medical field as a surgeon?
Dr. Kashmer: Like many people in health care, the reasons I went into health care were deeply personal. It had to do with the end of life care I observed for a family member and was centered on the manner and dignity provided for him by the medical field. Observing the excellent service provided, led me to decide that I wanted to help others as a physician and ultimately as a surgeon.
Bill: I’ve noticed over the past several decades, that there have been tremendous medical advances that have had big positive effects on life expectancy and quality of life. At the same time, medical care seems to be getting increasingly complex as new technologies are constantly evolving. What challenges do you see with the growing complexity and how does that relate to the quality of the service delivery of health care?
Dr. Kashmer: Bill, you’ve hit it on the head. Just as you say, health care is remarkable. As a group, we’re able to achieve incredible results for patients. The technology to do that has become increasingly complex. At the same time, just as you said, one of the opportunities we have is to innovate in how we provide those incredible services. We can make them more regular in terms of the outcome we expect and of higher quality and safety.
An Institute of Medicine report, “To Err Is Human”, is now well known throughout the country. The report is now more than a decade old, and describes that between 40,000 to 100,000 deaths occur due to medical errors in the Untied States each year. So, on the one hand, we see these incredible outcomes that we can have and yet the huge opportunity is on the quality front, not just be able to get these incredible results but to get the result regularly for each patient, each time. That’s really where the action is in my field and where it should be.
Bill: Dr. Kashmer, can you describe some quality improvement methodologies that can and are being applied to improve the health care mistake or defect rate?
Dr. Kashmer: Bill, we have a lot of them. What’s interesting in health care is I see us recreating the wheel to solve a lot of problems that have been solved in other industries. Although we’re starting to borrow from the aviation industry, it turns out that manufacturing and some tools at least as old as post-World War II Japan can be leveraged to great effect in health care.
Lean and Six Sigma are two of the techniques that can be used. They already exist, there’re prepackaged and they are statistically grounded and robust. These tools have been used for decades now in manufacturing industries and have experienced a lot of growth in use in service industries as well.
Bill: Have these methodologies already actually improved the quality of a health care process or system?
Dr. Kashmer: Yes, Bill. On a personal level, several of the systems I’ve been involved with have gone from a typical rate of defects, which in service industries is about one defect in every thousand opportunities, to what is know as the Six Sigma target rate of 3.4 defects or less for every million opportunities at making a defect.
That low level of medical error is especially tough to get to, but some systems I’ve worked with have achieved that level of error-free outcome. We have several systems from around the country that have been able to achieve that via the process and, after the systems have been revamped, the results that come out of that for patients have really been remarkable. Things that medical centers couldn’t do before they suddenly were proud to do and can do reliably.
Bill: Dr. Kashmer, this seems to be relatively recently applied in the medical field, at least from what I can understand. Is there much training in this methodology in medical education today?
Dr. Kashmer: There’s almost none. Although, we are given the rudiments of biostatistics in our training, those particular techniques and applications of statistics are very different than what’s done with process control. So no, Bill, there’s very little training in it, which is part of why it’s been my idea to be an advocate for its application in health care.
Statistical process control provides a different lens to view things than those in which medical providers are trained. It’s understandable that, as physicians, we can look at these tools and say, “But does that really apply? I don’t see how that would work,” because we’re trained for a high number of hours in many things, and yet we don’t see any of these tools. I think our skepticism about these techniques is natural and, in part, safe because we don’t want to go adopting whole new systems all the time. It’s conservative to follow the typical pattern of prevention of medical errors – however, that typical pattern is far less effective.
The fact is that, when properly applied, the statistical process control methods are very useful and work well. Once you’re educated in the tools as a physician and you understand the nuts and bolts of them, it gives you a completely different, valuable perspective that helps organizations and teams achieve great results for patients. That’s what it’s all about. I understand the skepticism and I had it too before I was trained in these things. Then, once you get the training and you see it in action, it’s really unbelievable. It’s a lot of what we’re looking for in medicine to solve issues that we all share.