
Image : http://www.flickr.com
AN OVERVIEW OF THE SITUATION
Performance improvement efforts at the hospital in this discussion were about eight years old at the time of this Emergency Department initiative. The institution consisted of 325 inpatient beds, with an emergency department of 26 rooms, seeing about 60,000 visits annually. Problems included chronic overcrowding in Emergency, often with all ED rooms filled, more than a dozen stretcher patients waiting for a room, and 70-100 more patients in the ED waiting area. The inpatient side of the house was frequently full, and diversion of incoming emergency patients to other hospitals 30 or more miles away occurred several times monthly.
Performance improvement efforts had included team projects related to the admissions process, discharge, bed placement, unit staffing, lab turnaround times, radiology flow, relay of information, and numerous other from clinical and administrative areas.
PREVIOUS ACTIVITIES
My own department (Performance Improvement) had the year before completed a major emergency process redesign involving the coordination of fourteen departments, all directly involved in the flow of patients and information through the ED. We had painstakingly designed ideal flow in the major areas of the larger process, and our recommendations to executive staff had been almost completely accepted, even though the price tag was in excess of $1.5 million dollars. It was discouraging to find that, even after five months of work and enthusiastic cooperation from all parties, there was almost no change in the flow of patients through Emergency.
FIRST STEPS TO A SOLUTION
At this point we were contacted by a large consulting firm which had been applying Eliyahu Goldratt’s Theory of Constraints (TOC) in manufacturing settings with significant success. They were familiar with our performance improvement process, and felt that together, we might be able to produce similar results in a hospital setting. Initial discussion made it obvious that if we could improve throughput in the Inpatient Process, it would likely open up the “impacted” Emergency Process, so that became our focus. After approval from upper management, the Performance Improvement Department staff began an initial investigation.
We began an analysis by interviewing a large number of employees, and about 1/3 of the physician staff, seeking common issues within the whole process. The results of those interviews, over 200 flip chart pages, were sifted down, with 20 suspicious areas being identified. Using the TOC conflict diagram we were able to identify several major themes of conflict, most arising from shared common high level goals!
WHERE THE CONFLICTS START
I should take the time to explain how this situation occurs, as it’s key to under-standing a)the origin of major inter-departmental conflict AND b) the cause of poor performance through the organization. A simple example arises from the corporate goal “Provide high quality clinical care”. Sounds like a good goal, huh? It IS, but watch what happens when that is translated by two different key departments:
Emergency Department Interpretation:
1) If we’re going to provide high quality clinical care, we must get the patient stabilized quickly, dealing with his immediate problems, and…
2) …Get that patient admitted to inpatient care as rapidly as possible.
Inpatient Nursing Unit
Interpretation:
1) If we’re going to provide high quality clinical care, we must meet all the needs of that patient, including clinical, psychological, and educational, and…
2) …To do this well, we need the right patient in the right unit (so the best care can be given), and we need the time to provide that necessary care.
Sound innocuous, doesn’t it? Watch what happens, though. Now you have one group of dedicated professionals seeking to get a patient stable and upstairs as quickly as possible, no matter what - “Get ‘em in, Get ‘em stable, Get ‘em admitted!”. But you have a second group, just as dedicated, who want the extended time it take to ascertain the patient’s current condition, develop a plan of care, implement the care, and educate the patient so that the care can be carried on even after the patient is discharged. “Get the right nurse with the patient, find out what’s needed, give the right care!” You can see, of course, that both plans will provide top notch care, but the result in hospitals is chaos!
Conflict #1…
Emergency: “I don’t care if you have no beds in medical-surgical, put the patient in pediatrics if you have to! Get him a bed!”
Inpatient: “This patient is SICK. He needs nurses who understand his condition, can ask the right questions, and can give the right care! We won’t take the admission!” Sound familiar?
Conflict #2…
Emergency: “These patients are backing up down here. We’ve GOT to get these stable people out, so we can deal with the acute patients still waiting to be seen!”
Inpatient: “How can we give quality care when you’re trying to admit 5 patients to this floor? We haven’t finished the last 3 you sent us, and we’re already late with meds - give us a break!”
Is either group in the wrong? Of course not. Both are motivated to achieve the same goal - top quality patient care - but their resulting activities were in direct conflict with the activities of the other department.
And this is only one area, there were a number of others, all contributing to slower inpatient care, which blocked admissions, which backed up Emergency. Quite a mess!
INITIAL FINDINGS
The result? It was impossible to open up flow through Emergency until we could improve throughput in the inpatient units. And there were so many issues there that we needed to find the critical few that would make a real difference. That’s covered in Emergency Room Throughput Diagnosis Part 2: Removing the Blockage, by the same author.
The author of this article, Tim Connor, is president and founder of Rodeo! Performance Group, Inc., an Ocala, Florida-based group of facilitators working with businesses and executives who want to make their businesses competitive on a global scale. You may sign up for Rodeo’s monthly newsletter, the Wrangler, at this link: http://www.rodeopg.com/Rodeo_Upload_Site_6-2008/Contact_Rodeo_Performance_Group.html. Tim can be contacted there or by phone at 1-877-284-0009. Visit Rodeo! on the web at http://www.rodeopg.com
http://serverjoho.com/larryweber/ http://estherbaez.easyworldwidemall.com/ http://ronalddavies.kbrblog.com/