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.
Figure 1
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.
Figure 2
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.
Bob Sproull
No comments:
Post a Comment