UNM residents start to go Lean

Following Dr. Kaplan's talk, UNM the residents retreat broke into work groups.  I attended the one about emergency department patient flow.  The UNM hospital handles 90,000 emergency room visits per year but suffers from major congestion problems.  The number of hours of boarding patients as they await rooms on the medical floors has grown, and there are also a substantial number of patients (14%) who leave without being seen because of the waiting times.  This is not an unusual problem in American hospitals, particularly the safety net hospitals, which face financial limitations in increasing capacity.

As we all know from our Lean training, though, there are process improvements that can be made in virtually any setting.  The purpose of our work group was to introduce residents to some of the Lean concepts.  We focused in this session on sketching out a process flow diagram, or map, indicating the steps taken in caring for a patient.  The idea is to identify all the steps and then determine the amount of time required to carry out each step.  Two metrics are used:  The net time is the actual time taken in carrying out a step; and the gross time is the fully elapsed time within which the task is accomplished, including all delays, re-work, and the like.  In most organizations, the net time is a small fraction of the gross time.

Here you see chief psychiatric resident Peggy Rodriguez keeping track as the group outlined the steps between when a decision is made to admit a patient and his or her arrival on a medical floor.  Each discrete step is itemized, and two numbers are assigned.  The one on the left is the net time for the task, and the one on the right is the gross time.

Were we doing this for real, all participants in the ED process would be engaged in creating this process flow diagram.  As the University of Michigan's Jack Billi would remind us, when a map is constructed to enable all to all aspects of the value stream, "it's not the map that's valuable.  It the process of mapping, which produces a shared understanding of the value stream and which enables the front-line team to design improvement experiments together."

This map, though, was being set forth for instructional purposes,  next you see Dr. Marc-David Munk, one of the leaders of the session, reading off the summary chart.  Peggy kept track and prepared the following summary chart.  Our rough analysis -- just based on perceptions of people in the room -- yielded 853 minutes of gross time spent per patient for work that had a value of 71 minutes.  This is remarkably close to the 14 hour average delay that the ED has documented.  The next step, if we were actually doing this in the hospital, would be to identify measures that could be taken to redesign the work flow and conduct experiments to see what would be helpful in extracting waste out of this overall process.

Dr. Kaplan addresses GME patient safety retreat in New Mexico

I am in Albuquerque, New Mexico, for a series of events related to patient quality and safety and process improvement in hospitals.  We are starting this morning with a graduate medical education retreat  entitled "Residents and Patient Safety" being run by the University of New Mexico School of Medicine.

The keynote speaker is Dr. Jay Kaplan, who practices emergency medicine in northern California and also works with hospitals throughout the country on clinical improvement matters.  I'll try to summarize key points as he talks.  His theme is "Driving Hospital Quality."

In his introductory moments, Jay noted that a rule of his department is bedside change of shift report.  He presented a recent example from his own last shift of such a handoff to show that this protocol can help identify a patient's problems that would otherwise be missed.

His major point is that customer service and quality of care are intimately related.  Quality is often viewed as the "hard stuff," while service excellence is viewed as "fluff stuff."  This is not accurate and misses the degree to which the latter affects clinical outcomes.  Quality gets you in the game; service lets you win.

One obstacle is that doctors have not been trained to be team players.  They need to learn how to collaborate.  Trained as craftsman, likewise, they are often not conversant in process improvement.

We have to focus on both systems and people.  We need people to buy into well designed systems.  Likewise, though, systems have to be designed to support great people.

Efficient patient flow requires aligned behaviors and cooperation between emergency departments and inpatient floors.

He asks the residents to ask themselves, "What do you do every day to bring quality and patient safety to your patients?"  Integrate service provision into this question.

Think bakery.  What does a customer notice upon entering?  The smell.  Do bakers notice it?  No, because they are used to it.  The analogy is:  When people first walk into your practice, clinic, or hospital, what do they notice?  What patients see, feel, and hear is different from what you and I see see, feel, and hear.  We are used to the environment.  They are not.  View your workplace from the point of view of the patients.

Here are some ideas.  Take a fresh look:  Change the signs.  Sit down when talking with patients, so they don't think you are in a hurry.  People will not hear all of your words:  Use key words that will be remembered.  As you pause to wash your hands, mention that you are doing so for their safety.  At the end of the visit, ask "What questions do you have for me?" instead of "Do you have any questions for me?"  They will always say, "No," to the latter.

Here is another set of ideas, based on the acronym ICARE:  Introduce yourself and Inspire confidence in the patient; Connect with the patient and family; Acknowledge what the patient has said; Review the plan of care and how long the various stages will take; Educate about what to expect and Ensure their understanding.

Another key strategy is to have follow-up phone calls to check on adverse reactions from drugs, to check on patient understanding, the patient's condition, etc.  This will also increase customer satisfaction.  The average time it takes to do this is two minutes and will result in some of the most rewarding feedback you will get from patients.

Reverse the expectation of punishment

An article in amednews.com reports:

[D]ata released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what's gone wrong.

These findings underlie the tragedy in medicine that results in thousands of preventable hospitals deaths each year and untold harm to other patients. Correcting this problem is a matter of leadership, plain and simple.  The clinical and administrative leaders of hospitals need to set a different standard.

I note this in my new book, Goal Play! Leadership Lessons from the Soccer Field:

You can see this philosophy in action through an event that happened at Beth Israel Deaconess Medical Center in July of 2008. A patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?” It was at that moment that the surgeon realized he had operated on the wrong limb. It is impossible to know who was more distraught, the patient or the doctor who realized that he had violated a life-long oath to “do no harm.”

It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure. Some were surprised by my answer, which was, “No.”

I felt that those involved had been punished enough by the searing experience of the event. They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient. Further, the surgeon immediately reported the error to his chief and to me and took all appropriate actions to disclose and apologize to the patient. He also participated openly and honestly in the case review.

. . . [A] wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”

I think he was exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them. And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.