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Something Interesting Happened


How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the hospital mdicine program and the hospitalist Training program, and as associate program director of the Internal Medicine Residency Program.

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