Managing Variability--The Problem

“’Managing Variability’ doesn’t look too tough, Curmudge. After your mentioning queuing theory and mathematical models in our last discussion, I was afraid you’d dump a pile of differential equations—whatever they are—on me.”

“Don’t worry, Jaded Julie. Math is too complex for a blog. But to temper your exaltation, I’d better warn you that we have a new Japanese word to learn. The word is heijunka, and it means ‘level loading.’”

“I know it must make sense in your ancient alchemist’s mind, Curmudge, but would you please share with me the connection, however tenuous, between heijunka and queuing theory. My brain is spinning, and we’ve only talked for three short paragraphs.”

“It’s really quite logical. Remember Dr. Deming’s writings about common-cause or natural variation as well as special-cause or artificial, man-made variation. We have both kinds in a hospital, such as the random patient arrivals in the ED and the man-made hills and valleys in people’s workloads caused by block scheduling of elective surgeries, morning rounds, and physician-requested early morning blood draws. Although hospital schedules are largely traditional, we must consider them man-made. As Pogo said, ‘we have met the enemy and he is us.’”

“(Pogo? Who’s Pogo? I’d better google him. Oh, Greybeard is probably just recalling some long-ago cartoon character.) So you and this Pogo-person (Pogo-thing?) are saying that traditional hospital routine is a man-made system designed to give hill-and-valley workloads, and ‘surprise!’ that’s what we get.”

“That’s it, Julie. We can’t begin to use queuing theory on the random variation until we have knocked the peaks off the artificial variation. That’s level loading or heijunka, and the study of the hills and valleys is called variability analysis.”

“But, Curmudge, traditional hospital routine is just the way it is. Don’t we have to live with it?”

“What you’re saying sounds a lot like, ‘We’ve always done it that way.’ That’s a very un-Lean statement that flies in the face of ‘continuous improvement.’”

“Sorry, Curmudge. When I get home I’ll wash my mouth out with soap. But what is so bad about variable workloads?”

“Dr. Eugene Litvak, the guru of queuing theory applied to health care, and his disciples feel that the OR is the driver of artificial variability. (1, 2) High-productivity surgeons tend to perform elective surgery on the same day every week. This impacts the whole hospital: admitting, discharging, the lab, housekeeping, and especially the availability of rooms for admissions from the ED. If a hospital’s midnight census is over 90%, it has very little capacity available for new admissions the next morning. (3) This might also cause internal gridlock, when patients can’t be moved from where they are presently (e.g., the ICU) to where they need to be (e.g., med/surg acute care). ‘Optimal care can only be delivered when the right patient is in the right place with the right provider and the right information at the right time.’ (3)”

“This must also affect the scheduling of nurses.”

“It does. If the hospital schedules nurses to accommodate the peaks, it incurs excessive costs. If nurses are scheduled to meet the average census, they are stretched to the limit in handling the peaks.”

“My guess is that nurses would rather have level loads than hills and valleys.”

“It’s more than just ‘rather,’ Julie. According to the literature (2), ‘overworked nurses and stressed resources raise the risk of error, increases staff dissatisfaction, and staff turnover.’ In addition, JCAHO says that 24% of sentinel events are associated with nurse understaffing.”

“That’s alarming, Curmudge. What can be done about it?”

“Next week we’ll talk about countermeasures. I hope you can wait.”

“I can wait if you will answer one question. Over the past year you have quoted a 19th Century novelist (Alexandre Dumas), several 21st Century professors (John Kotter, Jim Collins, and others), and now a 20th Century swamp-dwelling possum (Pogo). A possum? That doesn’t seem very scholarly.”

“Julie, I’d even go to the Okefenokee for the right kind of insight.”

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
(3) IHI White Paper, Optimizing Patient Flow, Innovation Series 2003. Institute for Healthcare Improvement.