By Zlatko Anguelov, MD
This was the core question I asked Sabi Singh, MS, MA Dr. Richard Johnston, MD, MS and Randy Fry,* all of them key boosters of process improvement at UI Health Care.
There is an old anecdote, said Mr. Fry, about a reporter who was covering the Apollo mission when we were going to the moon. One day the reporter went late in the evening to the NASA building, and there was nobody in but a janitor cleaning the floors. After chitchatting for a little while, the reporter asked the janitor: what is your purpose here? The man replied: to get a man on the moon. Well, wasn’t this the best evidence ever provided that the vision of an organization can and must cut across the whole organization from top to bottom?
The vision of UI Health Care today is patient-centered care. There is a general consensus that we provide the best possible medical care to our patients but we are short of the high standards in service. Service is about process: how to optimize all minute details that sum up the patient’s experience from entering the front door of our hospital to getting the highly specialized treatments the patient expects to get and come out the door healthier.
On the road to this vision there are those who began on their own, such as Dr. Johnston, and there are those who came here specially trained to teach the nuts and bolts of process improvement, such as Mr. Singh and Mr. Fry. Bringing them together and expanding their role throughout outpatient and inpatient clinics is a matter of time and long-term, committed effort. One of the keys to process improvement is the Kaizen event.
Kaizen is one of the fundaments of the Lean-based Toyota Production System; the name denotes an approach to continuous improvement by eliminating activities that do not provide added value. A Kaizen event is a workshop organized by management engineers for a group of frontline workers to set the base of Lean or Lean-like process changes that would be specific to the organization and would improve performance at all levels.
We had a four-day event, said Dr. Richard Johnston, involving a group of frontline workers who worked with me: a nurse manager, the nurses on the floor, and everybody else who cares of inpatients. Our goal was to improve workflow while caring of inpatients. One element of the workflow is to have a nurse to be with the physicians all the time when they go to see the patients. This did not happen before because of the way the workflow was routinely set. It was discussed at the Kaizen event as an opportunity for improvement. We wanted to have the same nurse with the same physician all the time.
Now that has been changed, said Mr. Singh, and doctors like it. The nurses give feedback to Dr. Johnston on a continuous basis and discuss both the positive and negative aspects of the new process. One expected outcome is that it reduces the LOS, another that the patient satisfaction improves. The nurse and the physician are on the same page. And this happened in an area with a very high volume of patients. We are actually making progress: the number of re-works has gone down from 3% to 0.5% and the LOS has been reduced by half an hour. Of course, it will take some time to go to the next level. Now, we are measuring to see how much increase there is in patient satisfaction.
There are other steps in-between that we’re doing without Kaizen, cuts in Dr, Johnston. For example, we are thinking now of scanning the documents of consent. It is a big frustration if, at the day of surgery, the permission on operating is not signed off by the patient. It’s a paper document; sometimes between the time it’s signed and the patient gets in the OR it gets lost, and when that happens, it throws a wrench in the situation. So, we’re just now beginning to scan and make this information functional online: we will have it stored online so that it doesn’t get lost, which currently happens at least twice a week.
Another example is the X-ray orders that are causing a lot of problems: the patient’s appointment is made on the DX system, and the X-ray order on IPR. When we make the order, IPR sends a message to DX to connect the order with the appointment. That’s OK. If the patient calls, however, and changes the appointment, and I’m told that 25% of the calls are for changing an appointment, then, the order doesn’t follow to the new appointment. We’re working on trying to solve that.
Something that helps with intra-clinic communication, Dr. Johnston goes on, is the creation of a computer dashboard: on a computer screen everyone marks at which stage and where the patient is during the day. The schedule for the clinic comes from DX. When the patient checks in, that sends a signal and records it; when we put a patient in a room, the system reports the time and shows where this patient is. It tells you if the patient has an X-ray, it tells you when they have completed the forms they had to complete. It’s been used a few months, and like with all new things, we have some cultural problems, how everybody’s using it. But it’s been a major breakthrough.
One of the shortcomings of a Kaizen event in the hospital environment is not the event itself, but that it is very hard to get doctors involved. The practicality of getting a bunch of orthopaedic surgeons sit around for several days, Dr. Johnston admitted, is not very great. Number one, they cannot be taken off their clinical duties for a whole day, and number two, it is not very enjoyable. We may have them on call, though. Also, there are physicians who have ideas, and we try our models with them first. Kaizen is just the beginning; it’s an ongoing process. It takes months and years to get to the perfect state. We continuously meet with those people, to keep up on how we progress.
But to what extent are the physicians aware of what’s going on? How they follow into this? They are the most important players, said Dr. Johnston. Our work is so involved in the day-to-day patient care that they cannot fail to be aware. They are aware of what’s happening, of why it’s happening; they have the opportunity to enter a dialogue to tell what they think about what’s happening. I spend a great amount of time networking with them. There are a lot of suggestions. Some of them are crazy, but many are good. And most of those get implemented.
The focus of another Kaizen event was to look at why the nurses were having difficulty planning the patients’ discharges and getting people out the doors. So, the initial problem presented to us, tells me Mr. Fry, was how we can take the distractions away from the nurses so that they can plan their day. We started with the nurses because that was our first bottleneck. Even if the nurse knew that her patient was going to be discharged that day, there wasn’t much planning of what had to be done that last day. For example, we may have things happening before the patients go home: for example, they need to do physical therapy so that the physical therapist can give their final OK for a discharge. There are many practical ways to schedule an appointment with the physical therapist without affecting the discharge time. But the nurses were going in so many different directions that they were unable to plan their day, they were reacting, they were firefighting. And so, we attacked things that were distracting them from doing the discharges, looking at calls, information, and those types of things.
Another issue we addressed, says Mr. Fry, was getting a nurse to do the right things when she goes into a room; to address patient needs in a consistent way. We looked at call-lights; there were days when they had 250 call-lights from a patient and when we looked at that, we said, probably half of those would be preventable if the nurse goes into the room and asks the right questions or looks at the right things. We tried to script this. Now, we’re starting to see an improvement there. But, like in manufacturing, if you have a bottleneck in your assembly line and you fix it, the bottleneck appears somewhere else. So, you’re continually looking at what is your constraint.
Mr. Singh summarized the results of this event as follows. Our preliminary data showed that the discharge of orthopaedic patients was happening between noon and 4 pm. That has shifted by two hours now, between 10 am and noon. Also, the nurses now make mandatory rounds: they go to the patient rooms every hour. That increased the patient satisfaction and reduced the pushing of the call-lights by 40%.
Yes, that’s the kind of stuff we’re dealing at this stage, adds Mr. Fry. We are still at the stage where we are picking the low hanging fruit. But I have no doubt that one day the bottleneck will shift to the doctors. Even today we see in our patient satisfaction surveys that the consistency of information between what the doctors say and what the nurses say and what the patients hear is far from optimal. So, we started to work with doctors. We asked Dr. Johnston: how can we come up with a discharge checklist in a kind of a timeline? If we know that a patient is going home, how much of that can we standardize? Do we catch 80% of the items, 90%? The reasons why doctors cannot be fully committed to a Kaizen event are obvious. Sometime it’s availability, sometime it’s planning. When we’re doing an event we have a wrap-up every day, and it’s usually the last 20-30 minutes of the day. At the bare minimum, we would like to see doctors attend this part. We don’t hope that doctors are going to spend a whole week with us, although that would be the ideal situation. Since we cannot have them fully involved, our alternative is to have them on call, so that, if we find a topic where we need their input, they come over and spend an hour with us, while we’re looking at their area.
Does he consider doctors frontline workers? Yes, Mr. Fry said, we would like to have doctors involved as such. Are there signs that doctors will be engaged? I think that they will. And I think that it’s the patient focus that will address that; it becomes a team effort by all the staff: from the doctors to housekeeping. And in our teaching hospital—because it’s a teaching hospital—the residents!
Residents are the most engaged in patient care here. They are spending more time on the floor; they’re the ones who are directly in charge of the patients. They are supervised by the faculty: they spend a lot of time training the medical side, which is important, but sometimes they need to look at the things that go around that. I remember at some meeting of a group of residents and the staff doctor, the issue was how the residents can adjust their schedule so that they can go on rounds with doctors. Residents have a lot of activities that are going on at the same time. So, they adjusted their schedule. Somehow over the years everything was falling at 7 am, when they thought they should have their free time so that they make the round. The staff physician said I always make sure I go get the nurse, but I don’t think of the resident. When we bring in a new resident, do we stress the importance of this communication and adjustment?
Another thing we did with our social workers and nurse managers was talk to Dr. Johnston about rotating doctors and residents, and also how can we educate new residents, get a little bit of time before they start in September and tell them: see, to facilitate the patient stay, these are the things that need to happen.
Something we hear consistently is how we can improve the communications between the doctors, the residents, the nurses, and the patients, so that the patient receives a consistent message. We want to minimize those surprises, when a nurse said she heard from the patient that an X-ray had to be done on him.