Managing Variability--Countermeasures

“Curmudge, the last time we talked you and some swamp-dwelling possum were telling me that the hills and valleys in hospital routine were man-made. You also said that handling the workload peaks stressed the staff and reduced the patients’ safety and quality of care. Finally, you promised to tell me what can be done to improve this situation. Now’s the time. What’s the word?”

“Lean.”

“Lean? Is that your one-word, one-size-fits-all default answer?”

“Well Jaded Julie, if you must have a second word, it’s heijunka or level loading. But in this case, heijunka is more of a goal than a tool. People in a hospital with high variability need to employ the Lean philosophy and techniques that we have been talking about for the past several months. Kaizen or rapid process improvement events, current- and future-state value stream mapping, go to gemba, A3 reports, the Deming cycle…the whole Lean Geschäft (business).”

“Easy, Curmudge. Please limit your enthusiasm to English words.”

“Getting the right people on the team is most important. If physicians will be impacted, they must become active and engaged team members. Not just any docs; they must be the docs that the others respect. The team should first look at variability and identify that which is man-made. When I say ‘look at,’ that means to go to gemba, gather data, and construct value stream maps. Plan and evaluate trials of changes that might smooth out the variability (plan-do-check-act). Consider any process element where ‘batching’ occurs to be a candidate for smoothing.”

“All of that sounds like Lean with a capital ‘L’, Curmudge. Have any hospitals undertaken this kind of effort?”

“You can read about them in the presentations by Litvak (1) and Paulson (2). They suggest that quality of care can be increased ‘free of charge.’ These are some of the benefits that have been achieved (1):
· Reduced ED diversions
· Greater staff and patient satisfaction
· Reduced mortality and medical errors
· Reduced length of stay
· Increased hospital throughput
· Increased surgical throughput”

“I presume that after a hospital has smoothed out its artificial variability it can better manage its natural variability with queuing theory.”

“That’s the idea, Julie. Characteristics of a system that one must know are the average patient arrival rate and the system’s average service rate. One can then determine staffing and numbers of rooms that will be needed to meet demand. Some of this is shown in the presentations that have been cited (1, 2). Other situations are described in the notes from Litvak’s ‘Queuing Theory’ course offered through IHI. Additional study will be needed to tackle more complex scenarios.”

“It sounds as if you are saying that for tougher situations I’m on my own.”

“Julie, as long as I am here, you’ll never be on your own. And don’t forget my colleagues in the Kaizen Promotion Office.”

Affinity’s Kaizen Curmudgeon

(1)http://www.iom.edu/Object.File/Master/21/207/Litvak_Variability%20in%20Patient%20Flow_updated.pdf

(2)http://www.hospitalcouncil.net/Upload/BEACON_PAULSON_IntrodImprovingInpatientFlow_4-24-07.pdf