Today we have another guest post from fellow blogger Mark Graban of LeanBlog.org, one of the top-read blogs about Lean today. Mark is a Lean consultant in healthcare and frequent keynote speaker at conferences, but many of his blog posts also cover Lean topics in sports. He has even created an ebook of his posts about sports. I have contributed a handful of articles to his blog, and he and I collaborated on his LeanBlog podcast in April about Lean in sports. He contributed a guest post last month about Bryce Harper and warning tracks. He was instrumental in my start as a Lean blogger and I’m extremely grateful for his support. Follow Mark on Twitter at @MarkGraban.
Gronk’s Surgery and What You Should Know about Post-Op Infections
By Mark Graban
Rob Gronkowski (it’s more efficient to call him “Gronk”) is, of course, an All-Pro tight end for the New England Patriots. He’s also a notorious shirtless dancer and surgery undergoer. Tuesday, he underwent back surgery, his seventh surgery since 2009, including four procedures on his forearm over the past year.
The first two Gronk arm surgeries were required to address fractures that occurred in NFL games (an occupational hazard, to say the least). His third surgery, in February, was necessary to clear out an infection that set in after the second procedure.
Why is this worth pointing out? A post-op infection isn’t just a necessary risk from surgery. It’s increasingly seen as something that shouldn’t happen if everybody involved in the surgical team, including the patient, does everything right the first time.
Pats quarterback Tom Brady was slowed down by a staph infection (click at your own risk) in 2008, after knee surgery. As reported, Brady required three additional surgeries to clear out the infection. Infections like this can lengthen the players’ recovery time, creating a huge risk or financial loss for NFL teams as a player misses more games or even has their career jeopardized.
How common are knee surgical infections?
Infections are unusual in knee surgeries in any case, [Dr. Riley Williams] said. He led a study in the 1990s that found an infection rate at the Hospital for Special Surgery of 0.3%, which had not changed much since. “I know it’s less than 1%,” he said.
The general risk for surgical-site infections is approximately 1 to 3% (2 to 5%, by some studies). An estimated 40 to 60% are preventable, if not more. These infections lead to higher cost ($3-10 billion annually in the U.S.), longer hospital stays, and higher mortality (3% of patients die from their surgical-site infections).
Beyond the uncertainty caused for fantasy football rosters, why should we care about surgical infections? Because they can happen to any of us.
Joint replacement, such as a knee or hip, is increasingly common with modern technology and an aging population (not just retired athletes). The Wall Street Journal reports infection rates can be “as high as 1.6% for knees and 2.4% for hips, or as many as 20,000 surgical infections per year.”
Surgical site infections (and other hospital-acquired infections) are increasingly seen as preventable, rather than being inevitable. As reported in the WSJ, there are a number of basic process steps that are shown to reduce infection rates, including:
– Giving antibiotics before surgery (at the right time)
– Removing hair with clippers instead of shaving (which avoid small cuts that could let bacteria from your skin enter your bloodstream)
– Prepping skin with alcohol-based antiseptic
– Showering or bathing with an antiseptic soap in the days leading up to surgery
See also the CDC’s guide to what you should know before surgery.
It’s a basic Lean principle that having a better process leads to better results. If we can make it more likely for people to do things right the first time, we’ll get better results, including fewer infections.
[Chad’s note: the term used for preventing processes from doing things improperly is known as error-proofing or “poka yoke.” A perfectly error-proofed process means that a bad output or result is impossible to create. An example of this would be a USB plug – you cannot put the plug in incorrectly, it only goes in one way. To reiterate what Mark stated, by error-proofing the pre-op, procedural, and post-op care for surgeries we can minimize the likelihood of infections…and in the cases of Brady and Gronk, a lower likelihood of multiple surgeries that would potentially keep them from helping the Pats win on the field.]
Now, do any of those steps sound like any sort of fancy or expensive medical technology? Not at all. But these steps are not followed 100% of the time. It’s impossible to speculate about whether the Gronk or Brady infections occurred even after all of the proper precautions being followed. But if you’re a patient, you can ask your surgeon what their process is for guaranteeing that these precautions will be taken and if they are aware of best practices.
The hospital can likely do more to make sure clippers are always readily available, otherwise a surgical team might be rushed and decide to use a razor to save time. The hospital might also need to hold surgeons accountable if they regularly refuse to give antibiotics to their patients (except, of course, when allergies or other factors are involved).
Another challenge for patients is that it can be very difficult to get data about infection rates for different surgeons or different hospitals. The state of Washington has a website that shows comparative data, but many hospitals show “no data available.” But this sort of data can’t be found in all states or countries.
98% might sound like a pretty good level of quality, but two “defects” out of 100 increases the chances that an infection will occur. I don’t think I’d like to be that one patient out of 50 who isn’t given the best standard of care… I don’t want that risk, if it can be avoided (and it can).
I had a chance to visit the South West London Elective Orthopaedic Centre (SWLEOC) back in 2009. This hospital performs total joint replacements – knees and hips. Through the use of the Lean methodology to improve processes, SWLEOC ensures that the best care is provided to each patient, making sure key steps and preventative measures always happen. As they explained to me, they have “better, more standardized processes” and more consistent surgical teams who work together more frequently.
As documented in their 2009 annual report, SWLEOC went an ENTIRE YEAR without a postoperative infection (see pages 36 and 37) – and that was with performing about 250 procedures a month.
If the typical infection rate is about 2%, we could have expected to see 60 infections… but SWLEOC had zero. Their 2010 report talks about the Lean process that has led to better care:
EOC managers and clinicians have been working effectively at increasing efficiency and reducing waste through adopting a lean philosophy in order to meet the demanding productivity and quality improvements that the Unit needs to deliver. The EOC staff have embraced the need for continuous quality improvements that refine The EOC’s pathways, reduce costs and increase throughput through its state of art surgical facility.
They had another year without an infection, as the data shows from their report:
The best in healthcare, via Lean, shows what’s possible, even if some hospitals and surgeons still think zero post-op infections is an impossible goal.
As coach Vince Lombardi once said, “Perfection is not attainable, but if we chase perfection we can catch excellence.”
Maybe we’ll see a day where our favorite players and best players don’t get post-surgical infections… and neither will we, the fans.
Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. Learn more about Mark’s on-site and public workshops. He is also the Chief Improvement Officer for KaiNexus. He blogs regularly at http://www.LeanBlog.org.