“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
Thursday, July 30, 2009
Thursday, July 16, 2009
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.
“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.
Thursday, July 9, 2009
An Introduction to Queues
“What’s a ‘cue-you,’ Curmudge?”
“It’s not a ‘cue-you,’ Jaded Julie; it’s pronounced just like the letter ‘Q.’ It comes from the French word for tail, and it means a line of people waiting their turn. So when you walk into McDonald’s, you are at the tail end of the tail.”
“Well that’s something everyone should know. If you can justify this enlightening discussion, now would be an excellent time to do it.”
“Of course, Julie. Today we are going to talk about customer flow management, a part of which is queuing theory; and before you ask me ‘why?’ I’m going to tell you why. An important aspect of the Toyota production system is one-piece flow. They build cars in an essentially continuous process with minimal inventory, work in process, and waste. Wouldn’t our patients be delighted if we could treat them in a similar, efficient process?”
“They definitely would like to be treated efficiently but probably not like a partially-built car. While patients are sitting in a waiting room, it probably wouldn’t make them any happier to think of themselves as ‘work in process.’”
“You’re right as usual, Julie. We certainly must treat our patients with respect, dignity, and compassion. But for today’s discussion, let’s think of patients as people who just want to arrive, receive a service, and depart ASAP.”
“Okay, Curmudge. I’m with you, at least for the moment. But if any of our discussion is going to involve queuing theory, I really need to know what that is.”
“Queuing theory uses mathematical models in analyzing how to match demand (usually variable) with capacity (usually fixed). Unfortunately, there’s a major limitation to elementary queuing theory: it can only be applied when customers arrive in a random manner. It doesn’t apply when service is provided on an appointment basis, which excludes most of the hospital. The ED and walk-in clinics would be examples of where patients arrive randomly.”
“If the use of queuing theory is so limited, why should we even study it?”
“Traditionally, when a patient walks into a clinic or hospital they expect they will have to spend time waiting. If queuing theory might help shorten waiting times, it’s certainly a subject with which we should have an acquaintance.”
“I guess it’s okay to get acquainted, but I don’t want to get too close to any mathematical models. Can you give me a non-mathematical introduction?”
“I’d be delighted, Julie. Linear queuing means that the customer waits physically in a line. (1) The simplest version is Single-Queue-Single-Service-Point, like waiting in line to buy your ticket for a popular movie. Several of these side-by-side make a Multiple-Queue-Multiple-Service-Point system like in a grocery store. This can be made more efficient by adding Segmentation, where certain lines handle only customers with 15 items or less. The most advanced form of linear queuing is Single-Queue-Multiple-Service-Points. A common example is the Post Office, where the line is not held up when one of the clerks is delayed by a customer sending a package to Timbuktu.”
“I must admit that I haven’t given much thought to the type of queue that I’m in. I do know that in the grocery store Erma Bombeck’s Law applies, ‘The other line always moves faster.’” (2)
“There are several variations on these simple systems. One is virtual queuing, where, after registering, a customer is sent to a waiting room rather than a physical line. Because the customer does not know his/her exact position in the queue, the staff is able to exercise some segmentation. An example would be an ED in which more urgent patients are seen first. A variation of this, virtual queuing with buffering, is also used in an ED; the next patient to be seen is taken to an exam room (the buffer) to minimize the service provider’s delay.”
“I know there are more, Curmudge. There always are.”
“Another fairly simple one is the multiple stage system in which the customer is served by more than one facility before leaving. This is termed ‘serial servers.’ I’ve seen this in European fast food restaurants where one decides what he wants, lines up to pay for it, and then lines up again to receive the food in exchange for the receipt. A similar system exists in a hospital where an outpatient must go to the lab and then to radiology.”
“Is there no end to this, Curmudge?”
“There is for us today, Julie, and it’s right now. Let’s go down to the cafeteria and stand in a queue.”
Affinity’s Kaizen Curmudgeon
(1)http://www.q-matic.com White Paper: An Introduction to Customer Flow Management
(2)Maister, David H. Note on the Management of Queues, Harvard Business Review (March 17, 1995): 1-14, Reprint #9-680-053.
“It’s not a ‘cue-you,’ Jaded Julie; it’s pronounced just like the letter ‘Q.’ It comes from the French word for tail, and it means a line of people waiting their turn. So when you walk into McDonald’s, you are at the tail end of the tail.”
“Well that’s something everyone should know. If you can justify this enlightening discussion, now would be an excellent time to do it.”
“Of course, Julie. Today we are going to talk about customer flow management, a part of which is queuing theory; and before you ask me ‘why?’ I’m going to tell you why. An important aspect of the Toyota production system is one-piece flow. They build cars in an essentially continuous process with minimal inventory, work in process, and waste. Wouldn’t our patients be delighted if we could treat them in a similar, efficient process?”
“They definitely would like to be treated efficiently but probably not like a partially-built car. While patients are sitting in a waiting room, it probably wouldn’t make them any happier to think of themselves as ‘work in process.’”
“You’re right as usual, Julie. We certainly must treat our patients with respect, dignity, and compassion. But for today’s discussion, let’s think of patients as people who just want to arrive, receive a service, and depart ASAP.”
“Okay, Curmudge. I’m with you, at least for the moment. But if any of our discussion is going to involve queuing theory, I really need to know what that is.”
“Queuing theory uses mathematical models in analyzing how to match demand (usually variable) with capacity (usually fixed). Unfortunately, there’s a major limitation to elementary queuing theory: it can only be applied when customers arrive in a random manner. It doesn’t apply when service is provided on an appointment basis, which excludes most of the hospital. The ED and walk-in clinics would be examples of where patients arrive randomly.”
“If the use of queuing theory is so limited, why should we even study it?”
“Traditionally, when a patient walks into a clinic or hospital they expect they will have to spend time waiting. If queuing theory might help shorten waiting times, it’s certainly a subject with which we should have an acquaintance.”
“I guess it’s okay to get acquainted, but I don’t want to get too close to any mathematical models. Can you give me a non-mathematical introduction?”
“I’d be delighted, Julie. Linear queuing means that the customer waits physically in a line. (1) The simplest version is Single-Queue-Single-Service-Point, like waiting in line to buy your ticket for a popular movie. Several of these side-by-side make a Multiple-Queue-Multiple-Service-Point system like in a grocery store. This can be made more efficient by adding Segmentation, where certain lines handle only customers with 15 items or less. The most advanced form of linear queuing is Single-Queue-Multiple-Service-Points. A common example is the Post Office, where the line is not held up when one of the clerks is delayed by a customer sending a package to Timbuktu.”
“I must admit that I haven’t given much thought to the type of queue that I’m in. I do know that in the grocery store Erma Bombeck’s Law applies, ‘The other line always moves faster.’” (2)
“There are several variations on these simple systems. One is virtual queuing, where, after registering, a customer is sent to a waiting room rather than a physical line. Because the customer does not know his/her exact position in the queue, the staff is able to exercise some segmentation. An example would be an ED in which more urgent patients are seen first. A variation of this, virtual queuing with buffering, is also used in an ED; the next patient to be seen is taken to an exam room (the buffer) to minimize the service provider’s delay.”
“I know there are more, Curmudge. There always are.”
“Another fairly simple one is the multiple stage system in which the customer is served by more than one facility before leaving. This is termed ‘serial servers.’ I’ve seen this in European fast food restaurants where one decides what he wants, lines up to pay for it, and then lines up again to receive the food in exchange for the receipt. A similar system exists in a hospital where an outpatient must go to the lab and then to radiology.”
“Is there no end to this, Curmudge?”
“There is for us today, Julie, and it’s right now. Let’s go down to the cafeteria and stand in a queue.”
Affinity’s Kaizen Curmudgeon
(1)http://www.q-matic.com White Paper: An Introduction to Customer Flow Management
(2)Maister, David H. Note on the Management of Queues, Harvard Business Review (March 17, 1995): 1-14, Reprint #9-680-053.
Thursday, June 25, 2009
Physicians and Lean
“Tell me again, Curmudge, about the connection between physicians and Lean.”
“It’s pretty simple, Jaded Julie. A hospital-wide Lean transformation must involve the physicians. It would be like trying to produce an opera without the star sopranos and tenors. On one hand, doctors don’t want to be told what to do, but at the same time, most are too busy to serve on the kaizen teams that work on improving hospital processes. That puts all of us—the docs as well as the hospitals—between a rock and a hard place.”
“The IHI White Paper that you gave me to read, Engaging Physicians in a Shared Quality Agenda (1), looks like the definitive work on the topic. (Did I say definitive? That’s a Curmudge word, not a Julie word.) But most people aren’t going to take time to read all of its 49 pages.”
“And that, Julie, is why we are going to use this blog to share some of its more important points. To begin with, throughout their education and training physicians have been taught to think and perform independently. As a result, to use the words of IHI, they have a ‘fierce attachment to individual autonomy’ and a deep sense of personal responsibility for the outcomes of their patients. Thus we need to improve their ‘systems’ thinking.”
“Lots of luck, Curmudge.”
“Physicians have a strong sense of collegiality. In that, we can see good news and bad news. Physicians will be slow to accept a change in procedure devised by ‘some nurse in an office,’ but they will be receptive to ideas presented by another physician whom they respect. To be accepted, one must ‘walk a mile in their moccasins’ almost on a daily basis. When you think about it, that’s pretty consistent with Lean; one must ‘go to gemba’ for meaningful knowledge.”
“I knew—sooner or later—that you would bring Lean into this.”
“Physicians are certainly acquainted with evidence-based treatments. Thus their thinking can be influenced by evidence they consider credible if it is presented properly and by the right person. Here are some other factors that should increase physicians’ acceptance of quality initiatives:
Select physician Project Champions who possess courage and social skills.
Identify respected ‘early adopters’ of the proposed changes.
Base proposed new protocols on medical evidence and test them locally on a small scale.
To the greatest extent possible, involve physicians in contemplated changes from the very beginning.
Couch proposed changes in physician-relevant terms such as better patient outcomes and less wasted physician time.
Make clear that proposed standard work is not ‘cookbook medicine.’ ‘Standardize what is standardizable; no more.’
Implement change incrementally, and make the right thing easy to do.”
“Hey, Curmudge, that sounds pretty straightforward, but I know that it isn’t. What’s the bottom line—the hook that will increase physician engagement?”
“Physician leaders, using incontrovertible data if they have it, must show their colleagues how participation in Lean events will bring about improvements in their patients, their practice, and their personal lives. And remember, Julie, success will breed success.”
“(Incontro…? Sounds like evidence-based.) Thanks for the insight, Old Guy. You may now return to your morning nap.”
Affinity’s Kaizen Curmudgeon
(1) http://www.ihi.org/IHI/Results/WhitePapers/EngagingPhysiciansWhitePaper.htm
Thursday, June 18, 2009
Communicate--Think--Diagnose--Communicate
“Tell me, Curmudge, why we are talking about how physicians think, diagnose, and communicate with patients, some of whom may be disingenuous (hey, I looked up the word).”
“To lead the list, Jaded Julie, it will make us better patients. It will also help us be more effective at enlisting physicians in the hospital’s Lean cultural transformation. We can better collaborate with the docs if we understand them.”
“Okay, let’s get under way. I assume like last week that all quoted material is from Dr. Groopman’s book (1).”
“Let’s begin by acknowledging that not all communication is verbal. At first sight, the patient looks at the physician and thinks to herself, ’Am I going to like and trust this person?’ And the doctor begins his diagnosis before the first word is spoken. If his nose is good, he can immediately sense that the patient is a smoker. Of course, sometimes these first impressions can lead the doctor down the wrong path. It’s hard to believe a person who appears ruggedly healthy is seriously ill (perhaps he is just here to get a flu shot). One might first suspect emphysema in a heavy smoker and cirrhosis in an unkempt boozer. Groopman calls these types of first impressions—when they turn out to be wrong—‘representativeness errors.’ These may also be called ‘attribution errors,’ when the patient fits a negative stereotype.”
“Groopman mentions some other types of ill-advised shortcuts leading to incorrect diagnoses. ‘Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind’ (most of my other patients today have the flu, so this patient must have it too). ‘Anchoring’ occurs when the physician doesn’t consider multiple possibilities but firmly latches onto a single one. In ‘confirmation bias’ one sees only the expected landmarks and neglects the others. Curmudge, all of these errors resulted from docs’ taking shortcuts. Does that mean that they are a no-no?”
“Julie, a chance encounter with The Happy Hospitalist blog (2) convinced me of the multitude of mental data points that must be considered in making an accurate diagnosis. The only way this can be achieved in a reasonable time is to take appropriate shortcuts—each based on sound clinical judgment—among the possibilities. Doctors are taught to be methodical, but they must learn to be efficient. This is what differentiates a physician from a technician with a checklist or an algorithm.”
“Then according to Groopman, ‘The key cues to the patient’s problem—from medical history, physical exam, x-ray or lab tests—coalesce into a pattern that the physician recognizes as a specific disease or condition.’ But, Curmudge, what if they don’t?”
“That may be a situation where the physician should listen to the little voice that says, ‘Don’t just do something; stand there.’ If the doctor senses that missing pieces are leaving blanks in the puzzle, he should work toward filling them. He may have to say to the patient, ‘I believe when you say something is wrong, but I haven’t figured it out.’ Sometimes he just has to wait until the problem ‘declares itself,’ usually by becoming worse.”
“Curmudge, what should the doc tell the patient when the diagnosis indicates a life-threatening or debilitating disease?”
“I recall in my youth when neither the physician nor the patient’s family would share with the patient the seriousness of his diagnosis. That’s when life-threatening almost certainly meant life-ending. Now many of those diseases can be cured or at least arrested. The physician can be upbeat when it is justified, and even in the bleakest situations assure the patient that he will not be abandoned.”
Affinity’s Kaizen Curmudgeon
(1) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(2) The doctor’s doctor: How to be an internist in five minutes. http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html
“To lead the list, Jaded Julie, it will make us better patients. It will also help us be more effective at enlisting physicians in the hospital’s Lean cultural transformation. We can better collaborate with the docs if we understand them.”
“Okay, let’s get under way. I assume like last week that all quoted material is from Dr. Groopman’s book (1).”
“Let’s begin by acknowledging that not all communication is verbal. At first sight, the patient looks at the physician and thinks to herself, ’Am I going to like and trust this person?’ And the doctor begins his diagnosis before the first word is spoken. If his nose is good, he can immediately sense that the patient is a smoker. Of course, sometimes these first impressions can lead the doctor down the wrong path. It’s hard to believe a person who appears ruggedly healthy is seriously ill (perhaps he is just here to get a flu shot). One might first suspect emphysema in a heavy smoker and cirrhosis in an unkempt boozer. Groopman calls these types of first impressions—when they turn out to be wrong—‘representativeness errors.’ These may also be called ‘attribution errors,’ when the patient fits a negative stereotype.”
“Groopman mentions some other types of ill-advised shortcuts leading to incorrect diagnoses. ‘Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind’ (most of my other patients today have the flu, so this patient must have it too). ‘Anchoring’ occurs when the physician doesn’t consider multiple possibilities but firmly latches onto a single one. In ‘confirmation bias’ one sees only the expected landmarks and neglects the others. Curmudge, all of these errors resulted from docs’ taking shortcuts. Does that mean that they are a no-no?”
“Julie, a chance encounter with The Happy Hospitalist blog (2) convinced me of the multitude of mental data points that must be considered in making an accurate diagnosis. The only way this can be achieved in a reasonable time is to take appropriate shortcuts—each based on sound clinical judgment—among the possibilities. Doctors are taught to be methodical, but they must learn to be efficient. This is what differentiates a physician from a technician with a checklist or an algorithm.”
“Then according to Groopman, ‘The key cues to the patient’s problem—from medical history, physical exam, x-ray or lab tests—coalesce into a pattern that the physician recognizes as a specific disease or condition.’ But, Curmudge, what if they don’t?”
“That may be a situation where the physician should listen to the little voice that says, ‘Don’t just do something; stand there.’ If the doctor senses that missing pieces are leaving blanks in the puzzle, he should work toward filling them. He may have to say to the patient, ‘I believe when you say something is wrong, but I haven’t figured it out.’ Sometimes he just has to wait until the problem ‘declares itself,’ usually by becoming worse.”
“Curmudge, what should the doc tell the patient when the diagnosis indicates a life-threatening or debilitating disease?”
“I recall in my youth when neither the physician nor the patient’s family would share with the patient the seriousness of his diagnosis. That’s when life-threatening almost certainly meant life-ending. Now many of those diseases can be cured or at least arrested. The physician can be upbeat when it is justified, and even in the bleakest situations assure the patient that he will not be abandoned.”
Affinity’s Kaizen Curmudgeon
(1) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(2) The doctor’s doctor: How to be an internist in five minutes. http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html
Thursday, June 11, 2009
Patient-Centered Communications
“Hey, Curmudge, everybody’s writing about the future of health care. Why don’t you take a daring leap and describe all-electronic diagnosis and plan of care? The technician will stick electrodes on the patient, push his arm through the bp cuff, and press a button. Then she will check the boxes on the diagnosis algorithm, send the data to a diagnosis reminder system like an advanced version of Isabel (1), and a Pyxis-like machine will eject the prepackaged meds needed to cure the patient. Amazing!”
“Please return to Planet Earth, Jaded Julie. Your plan totally excluded physicians. That’s not going to happen in my lifetime and probably won’t in yours. Let’s continue our discussion of the humanistic side of patient care. We’ve already talked about how nurses can make a difference and how patients can help themselves. Now let’s bring doctors into the discussion and focus on physician-patient communications.”
“Curmudge, we’ve both read Dr. Groopman’s book, How Doctors Think (2), so I presume it will be our principal resource. We don’t want our readers to think that our statements are the original thoughts of a fictional nurse and a semi-useless old man.”
“Thanks for the left-handed compliment, cher collègue; but if I must be semi-anything, I would prefer semi-useful. Anyway, unless otherwise indicated, quoted material will be from Groopman. To begin with, good communication with patients is not equally important for all physicians. It is vitally important for those in primary care, emergency medicine, pediatrics, internal medicine, and several other areas; but ‘the higher we go on the scale of specialist training, the less complex the medical problem becomes.’ So we’ll focus on communications by the docs who really need it—those involved in the initial encounter with the patient and who must make the initial diagnosis.”
“I’m disturbed, Curmudge, by the observation that, ‘on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.’ These data contradict the advice that if you listen to the patient long enough, in most cases he will tell you the diagnosis.”
“It’s more than just listening, Julie. The physician needs to ask leading questions and respond to the patient’s emotions so that the patient feels free to participate in a dialogue. The questions and the way they are asked will ‘shape the patient’s answers and guide your thinking.’ ‘Once you remove yourself from the patient’s story, you are no longer truly a doctor.’ A physician gains these communication skills from years of experience and from remembering his/her misguided decisions.”
“Cultural differences must make communication even more difficult (3, 4). Imagine the gulf between a young, white, female doctor and an elderly man of color. Or consider reversing race, role, and gender. It’s even worse when the doctor and the patient don’t speak the same language and have to converse through an interpreter. Bridging these gaps will take conscious effort; ignoring them could lead to serious misunderstanding.”
“Regrettably, Julie, not all verbal communications are helpful. Some patients may be disingenuous when describing their symptoms in an attempt at obtaining drugs. In a physician’s encounter with an intoxicated or drug-influenced patient, he must discern whether it is the patient or the substance talking. On the other hand, the physician must be careful not to overlook a valid medical problem in an impaired patient.”
“Disin…what? Well I suppose that if a druggie needs a fix bad enough, he might be untruthful. So Curmudge, what’s the bottom line?”
“We’re not there yet; we’ll talk more about this next week. But here is our lesson for today: ‘You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient.’”
Affinity’s Kaizen Curmudgeon
(1) http://us.isabelhealthcare.com/info/components_and_emr.jsp
http://hollandhart.typepad.com/healthcare/2006/12/medical_clinica.html
(2) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(3) Lasser, K. E., et al. Discussions about preventive services: A qualitative study. http://www.medscape.com/viewarticle/586215_print_print
(4)Kane, L. R. Patient communications: Solving today’s hurdles. http://www.medscape.com/viewarticle/587906_print
“Please return to Planet Earth, Jaded Julie. Your plan totally excluded physicians. That’s not going to happen in my lifetime and probably won’t in yours. Let’s continue our discussion of the humanistic side of patient care. We’ve already talked about how nurses can make a difference and how patients can help themselves. Now let’s bring doctors into the discussion and focus on physician-patient communications.”
“Curmudge, we’ve both read Dr. Groopman’s book, How Doctors Think (2), so I presume it will be our principal resource. We don’t want our readers to think that our statements are the original thoughts of a fictional nurse and a semi-useless old man.”
“Thanks for the left-handed compliment, cher collègue; but if I must be semi-anything, I would prefer semi-useful. Anyway, unless otherwise indicated, quoted material will be from Groopman. To begin with, good communication with patients is not equally important for all physicians. It is vitally important for those in primary care, emergency medicine, pediatrics, internal medicine, and several other areas; but ‘the higher we go on the scale of specialist training, the less complex the medical problem becomes.’ So we’ll focus on communications by the docs who really need it—those involved in the initial encounter with the patient and who must make the initial diagnosis.”
“I’m disturbed, Curmudge, by the observation that, ‘on average, physicians interrupt patients within eighteen seconds of when they begin telling their story.’ These data contradict the advice that if you listen to the patient long enough, in most cases he will tell you the diagnosis.”
“It’s more than just listening, Julie. The physician needs to ask leading questions and respond to the patient’s emotions so that the patient feels free to participate in a dialogue. The questions and the way they are asked will ‘shape the patient’s answers and guide your thinking.’ ‘Once you remove yourself from the patient’s story, you are no longer truly a doctor.’ A physician gains these communication skills from years of experience and from remembering his/her misguided decisions.”
“Cultural differences must make communication even more difficult (3, 4). Imagine the gulf between a young, white, female doctor and an elderly man of color. Or consider reversing race, role, and gender. It’s even worse when the doctor and the patient don’t speak the same language and have to converse through an interpreter. Bridging these gaps will take conscious effort; ignoring them could lead to serious misunderstanding.”
“Regrettably, Julie, not all verbal communications are helpful. Some patients may be disingenuous when describing their symptoms in an attempt at obtaining drugs. In a physician’s encounter with an intoxicated or drug-influenced patient, he must discern whether it is the patient or the substance talking. On the other hand, the physician must be careful not to overlook a valid medical problem in an impaired patient.”
“Disin…what? Well I suppose that if a druggie needs a fix bad enough, he might be untruthful. So Curmudge, what’s the bottom line?”
“We’re not there yet; we’ll talk more about this next week. But here is our lesson for today: ‘You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient.’”
Affinity’s Kaizen Curmudgeon
(1) http://us.isabelhealthcare.com/info/components_and_emr.jsp
http://hollandhart.typepad.com/healthcare/2006/12/medical_clinica.html
(2) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(3) Lasser, K. E., et al. Discussions about preventive services: A qualitative study. http://www.medscape.com/viewarticle/586215_print_print
(4)Kane, L. R. Patient communications: Solving today’s hurdles. http://www.medscape.com/viewarticle/587906_print
Thursday, June 4, 2009
Lean and Trust--Applications
“Jaded Julie, I presume you can trust your husband?”
“Couch Potato? I can certainly trust his character; his personal values are impeccable. (Impeccable? Did I say that?) But his competence is something else. He’s pretty good at clicking the TV remote. I guess with him, having one out of the two main dimensions of trust isn’t bad.”
“To a degree, Julie, a hospital is a bit like your husband. It should be safe to say that virtually everyone who works in a hospital has his/her heart in the right place. If a person had a shady character, they would go someplace else. People’s deficiencies and the reasons that we might not fully trust them are more likely to be related to their competence.”
“I need some examples, Curmudge, especially those showing a link between trust and Lean.”
“We’ve talked a lot about using Lean to minimize the eight types of waste, so there’s no need to list them. Let’s consider just one—inventory. People keep ‘rogue’ inventory (1) because they don’t trust the hospital’s system to always have what they need when they need it.”
“As a nurse in a patient care unit, my first thought would be that the person who does the restocking is incompetent. In reality, it probably means that the standard work for the restocking process has not been properly designed and implemented. That’s Lean with a capital ‘L’.”
“Right, Julie. And perhaps the restocking person appeared incompetent because he did not receive adequate training or the authority to increase the inventory when he saw it running out. That’s Lean too.”
“Here’s one, Curmudge. How about the time wasted due to excessive checking and obtaining unneeded approvals? These so-called requirements are put in place because we don’t trust somebody’s competence.”
“One of the most basic of Lean activities is the rapid improvement event that makes a process more efficient. The team members enthusiastically support the change because they own it. They trust their own competence and that of the other team members.”
“Hey, Curmudge, this is a slam-dunk. ‘Trust and be trusted.’ But are there some other threats lurking in the bushes that we haven’t discussed?”
“For the good of the order, Julie, I must confess to a skeleton hiding in my personal closet. During my first year as a lab manager, our lab had a big job to do for the corporation. I gave part of the job to a chemist that I knew to be brilliant, but at the time I didn’t realize that his memory leaked like the Titanic. Anyway, he forgot to do a critical part of the job, and our lab ended up looking like the Keystone Cops.”
“Wow, that’s no way to win a Nobel Prize. So what happened?”
“Of course, I viewed the chemist as having violated my trust in his competence. In addition, my boss felt the same way about me, and her boss probably felt the same way about her. The lesson here is that a middle manager is in the middle of a long chain of ‘trusts,’ and his job is to make sure the chain is not broken. In the current instance, my career with the company was almost truncated.”
“(Truncated? That must mean he came close to being sacked.) Well, Middle Manager, how did you avoid the axe?”
“It was intense service recovery, Julie. There were many 8:00 a.m.-to-9:00 p.m. working days devoted to regaining trust in the lab’s competence. I ended up working for the company 10 more years.”
“And then, Curmudge, you retired?”
“No. Then I was sacked, possibly because I was 66 years old. With a lot of hard work, one can overcome a perceived violation of trust, but you can’t hold back the sands of time.”
Affinity’s Kaizen Curmudgeon
(1) Martin, Karen. The Trust Factor. Industrial Engineer, p. 31-35, (March 2006)
“Couch Potato? I can certainly trust his character; his personal values are impeccable. (Impeccable? Did I say that?) But his competence is something else. He’s pretty good at clicking the TV remote. I guess with him, having one out of the two main dimensions of trust isn’t bad.”
“To a degree, Julie, a hospital is a bit like your husband. It should be safe to say that virtually everyone who works in a hospital has his/her heart in the right place. If a person had a shady character, they would go someplace else. People’s deficiencies and the reasons that we might not fully trust them are more likely to be related to their competence.”
“I need some examples, Curmudge, especially those showing a link between trust and Lean.”
“We’ve talked a lot about using Lean to minimize the eight types of waste, so there’s no need to list them. Let’s consider just one—inventory. People keep ‘rogue’ inventory (1) because they don’t trust the hospital’s system to always have what they need when they need it.”
“As a nurse in a patient care unit, my first thought would be that the person who does the restocking is incompetent. In reality, it probably means that the standard work for the restocking process has not been properly designed and implemented. That’s Lean with a capital ‘L’.”
“Right, Julie. And perhaps the restocking person appeared incompetent because he did not receive adequate training or the authority to increase the inventory when he saw it running out. That’s Lean too.”
“Here’s one, Curmudge. How about the time wasted due to excessive checking and obtaining unneeded approvals? These so-called requirements are put in place because we don’t trust somebody’s competence.”
“One of the most basic of Lean activities is the rapid improvement event that makes a process more efficient. The team members enthusiastically support the change because they own it. They trust their own competence and that of the other team members.”
“Hey, Curmudge, this is a slam-dunk. ‘Trust and be trusted.’ But are there some other threats lurking in the bushes that we haven’t discussed?”
“For the good of the order, Julie, I must confess to a skeleton hiding in my personal closet. During my first year as a lab manager, our lab had a big job to do for the corporation. I gave part of the job to a chemist that I knew to be brilliant, but at the time I didn’t realize that his memory leaked like the Titanic. Anyway, he forgot to do a critical part of the job, and our lab ended up looking like the Keystone Cops.”
“Wow, that’s no way to win a Nobel Prize. So what happened?”
“Of course, I viewed the chemist as having violated my trust in his competence. In addition, my boss felt the same way about me, and her boss probably felt the same way about her. The lesson here is that a middle manager is in the middle of a long chain of ‘trusts,’ and his job is to make sure the chain is not broken. In the current instance, my career with the company was almost truncated.”
“(Truncated? That must mean he came close to being sacked.) Well, Middle Manager, how did you avoid the axe?”
“It was intense service recovery, Julie. There were many 8:00 a.m.-to-9:00 p.m. working days devoted to regaining trust in the lab’s competence. I ended up working for the company 10 more years.”
“And then, Curmudge, you retired?”
“No. Then I was sacked, possibly because I was 66 years old. With a lot of hard work, one can overcome a perceived violation of trust, but you can’t hold back the sands of time.”
Affinity’s Kaizen Curmudgeon
(1) Martin, Karen. The Trust Factor. Industrial Engineer, p. 31-35, (March 2006)
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