These days it is difficult to turn on our televisions without hearing something about healthcare and with the impending Affordable Healthcare Act set to sweep into our lives just weeks from now, we will hear even more. Healthcare professionals openly express the fact that they must improve their ability to deliver high quality services. The fact is, people now have choices as to which healthcare provider they elect to use and their choices are based upon a variety of factors, not the least of which is how much “wait time” they will tolerate. Because of this, numerous consultancies have sprung up, all claiming to be able to improve the delivery of healthcare services. The problem is, many of these groups fail to identify the core problems and end up treating the symptoms (excuse the pun) rather than identifying and treating the true root cause of the organizational problems.
One of the glaring problems that I see with many healthcare consultants is the failure to consider the impact of their localized improvements on the overall healthcare system. Improvements are made in one area which can cause sometimes devastating negative effects in another. Consider the following:
· A team determined that there was a problem with the flow rate of patients entering a hospital Emergency Department (ED). They identified the need to “speed up” the time from patient registration until the patient was admitted to the appropriate hospital unit. The team was very successful and reduced the time by nearly 50%! This effort was hailed as a major success and rightfully so. However, because the team hadn’t included the discharge process, patients ended up spending too much time on gurneys in hallways because there were no beds available. This “effect” resulted in a rapid and significant deterioration of patient satisfaction scores. The team had made a localized improvement without considering the potential impact on downstream processes. If the team would have completed a system’s analysis, they could have predicted this negative result and quite possibly have studied and improved the discharge process before attempting to improve the flow through the ED.
· A team was commissioned to improve an Operating Room’s (OR) ability to increase the number of surgeries performed. The team determined that by improving the throughput of the OR, without adding additional staff, most of the new revenue should flow directly to the hospital’s bottom line. The team worked feverishly and was quite successful as the throughput of the OR improved by nearly 40%. What a great achievement and it was hailed as a major success!! The only problem was that this facility did not have enough staff or beds in their post-operative department (ICU) to handle this new volume of patients. This failure to consider the possible impact on ICU resulted in the need to call in staff on very short notice, the need to hire additional staff, and OR patients spending too much time in hallways while beds were freed up. The morale within ICU suffered and the hospital incurred significant additional operating expense (new hires) and just like the ED example, patient satisfaction scores took a negative hit.
Unfortunately, the failure to consider these obvious systemic effects, in favor of localized improvements, is an all too common practice in many hospitals and healthcare facilities. This practice is a classic example of a silo mentality. The question becomes then, how do healthcare facilities avoid these problems?
Let’s look at both scenarios (i.e. Hospital Emergency Department and Surgical Unit) to better understand the high-level flow of patients in each.
Per Figure 1, the patient enters the Emergency Department, registers, and then is evaluated by the doctor. The doctor then makes a decision regarding whether to treat the patient in the ED or admit the patient into a hospital unit. In the case of the doctor deciding to admit the patient, there must be a bed available for the patient. In the case of treating the patient in the ED, the impact on other functional areas within the hospital is not affected.
Suppose an improvement team is commissioned to reduce the time the patient spends in the ED. If the team only looks at the actions taken in the ED (i.e. localized improvements) without considering the impact on the healthcare system, there will be a negative impact on the receiving hospital units. Per my earlier example, if the team significantly increases the hospital admitting rate, then what impact might we see? One impact is that beds might not be available for incoming patients. Like our earlier example, incoming patients might spend an inordinate amount of time on a gurney in a hallway because no beds were available. Do you think patient satisfaction would be negatively impacted?
So what should have happened before this improvement team was commissioned? My recommendation would have been to study the discharge process first in anticipation of an increased load of admitted patients. By studying and improving the discharge process first, the negative impact on patient satisfaction scores could have been completely avoided. What should have happened was commissioning a team to improve the discharge process prior to improvements in the ED flow rate. In other words, by looking at the overall process to get the improvement sequence correct, the patient satisfaction scores might not have suffered.
In the case of the team that improved the flow of patients into and out of surgery, the same scenario is seen in Figure 2. The patient is first scheduled for surgery, is prepped and then has the surgery. When the surgery is completed, the patient is transferred to a post-operative unit where they are evaluated, treated and eventually discharged.
Like the ED example, if the improvement team does not consider the downstream process steps (i.e. both post-operative unit and discharge process), a negative effect will be felt in the post-operative unit (ICU). Once again, the discharge process should have been improved first, then the receiving unit (i.e. post-operative care unit), before improvements were made to the surgical unit. In other words, improvements made in isolation (i.e. silo mentality) WILL result in negative effects down-stream (and sometimes up-stream).
In the next several postings we will continue to address problems associated with not considering the system impact as well as other healthcare issues that must be addressed.