December 5, 2019

Rounds: Lessons on reducing waste from a DIY handyman

My father-in-law, Ron, was an accomplished businessman who prided himself as a quintessential do-it-yourself guy when it came to home repairs. I, being a good son-in-law, listened attentively trying to absorb his sage advice given I’m somewhat more challenged by these tasks.


by Jeff Balser, MD, PhD

My father-in-law, Ron, was an accomplished businessman who prided himself as a quintessential do-it-yourself guy when it came to home repairs. I, being a good son-in-law, listened attentively trying to absorb his sage advice given I’m somewhat more challenged by these tasks. (My wife’s description is undoubtedly more colorful.)

Ron imparted his wisdom via memorable one-liners with touches of sarcasm and overtones of compassionate understanding. One of

Jeff Balser, MD, PhD

my favorites came when I shared my frustration with the tile caulk in our bathroom shower, which despite constant fix-me-ups never seemed to stop cracking and peeling. “You caulk ‘til you die,” he told me.

This is one of my favorite metaphors.

It’s handy when talking about something that will perpetually require attention, no matter how often or how well we attend to it today. Next week, or next month, or next year, it will need to be adjusted, repaired, upgraded — or entirely replaced.

The build-up of waste in health care is never ending. It’s all around us, and taming it requires perpetual action. Much like Ron’s advice to caulk ‘til you die, curbing waste demands relentless focus.

Waste results from many things. But a big culprit is the variability we tolerate across dozens, hundreds, or even thousands of repetitive tasks. Think of it this way: what would it cost UPS to ship packages if every single gift was shipped using a custom container and a different process?

A recent review of literature published in JAMA pegged the annual cost of waste in the U.S. health care system between $760 billion to $935 billion — or a quarter of total health spending. Waste is everywhere, and the evidence is clear we can no longer afford it.

A pathway to reducing waste in all industries, including health care, is standardization. Yet, I’m a big advocate of personalization — an area of advancement where VUMC is a world leader. Our goal at VUMC is to define the standards for personalized care through redesigning the care experience around the special characteristics and preferences of each person — from their DNA sequence to their ability to access care, to their social, behavioral and environmental context.

So, am I speaking with a forked tongue? How can we advocate for standardization while simultaneously being committed to personalization?

The key is to build in personalization only where and when it matters, thereby making it a conscious choice. For instance, when a clinician selects a different drug or test rather than the “standard” because evidence and experience support the decision — that’s a conscious choice. We trust our medical teams when they are making deliberate, conscious choices about what care to provide, and how to provide it.

At the same time, we make unconscious choices. We do it while driving, at the grocery store and when performing many roles at VUMC. We make unconscious decisions based on our biases, traditions and even on recently acquired anecdotal information.

Yet, we know most clinicians — and frankly most people — will consistently make different and far better choices when provided with high quality information at exactly the right point: the perfect time is just at the moment when they are about to act.

Just-in-time decision support is key to tackling waste. And VUMC is a leader in decision support. In fact, we developed one of the nation’s first drug order entry systems with decision support back in the 1990s, the utility “WizOrder” many will recall.

Last year I testified before the U.S. Senate Health, Education, Labor and Pensions Committee on the subject of health care waste. In preparation, I worked with pharmacy leadership to understand the financial impact of the digital decision support we offer to clinicians as they order drugs.

We have an incredibly robust and active Pharmacy & Therapeutics (P&T) Committee, staffed by a broad range of pharmacy and clinical specialists who continually review literature on efficacy, cost, side effects and other information impacting drug selection. Using eStar, we “push” that information to clinicians as they electronically order treatments at the point of care.

Naturally, clinical teams can opt for an action other than the recommendation because the system can’t anticipate every circumstance. Yet, the cost savings from providing well-timed recommendations that are followed in the vast majority of cases is staggering. VUMC saves about $35 million annually on inpatient drugs alone, compared to the average medical center with comparable acuity and volume of patients.

With that success as a springboard, there’s now a “Lab Formulary Committee.” While it’s still the early days for this program, this year it will save more than $3 million by providing expert guidance during ordering processes, particularly for complex esoteric testing and genetic testing.

Labs and drugs are only the beginning. We developed an innovative clinical trials system to evaluate daily processes we may take for granted. Determining what practice is actually “better” requires large numbers of study patients.

Our global research data capture program, REDCap, and a cluster randomization approach allow us to study real-time outcomes as patients receive two kinds of care that, as far as we know, are therapeutically equivalent. An example is more selective use of chlorhexidine bathing, a costly practice that in many ICU cases didn’t control the incidence of infections better than other, less expensive options. Dozens of these “pragmatic trials” are now happening, including assessing whether wearing protective garments when caring for inpatients colonized with certain kinds of bacteria actually affects infection rates.

We can make more room for the things that really do matter — the aspects of care and expertise that change lives — by working to strip out more of the unconscious choices.

This is where everyone can make a difference: pinpoint practices and routines you suspect are unnecessary and costly. Email ideas for “crushing waste” to CRUSH.WASTE@VUMC.ORG

We can never stop uncovering and eliminating waste. Old habits find their way in and will always show up, just like the caulk between the shower tiles will always crack.


Jeff Balser, MD, PhD

President and CEO, Vanderbilt University Medical Center and Dean of Vanderbilt University School of Medicine