“Curmudge, what’s this more 1940 stuff? We talked about that last week. Didn’t you get it all out of your system?”
“Actually, Jaded Julie, I didn’t. I simply remembered more. My mind runs rather slowly in reverse.”
“Sure. About the same as your top forward speed. Okay, so what’s your story? Was everything better or worse back then?”
“Some of each, Julie. Remember my telling about our family doctor cutting out my ingrown toenail? Well, it got infected. It hurt like mad, and when Dr. Arnold took off the bandage, it looked ghastly. I was afraid we’d have to use gentian violet or whatever the purple stuff was that he used to treat my impetigo a couple years before. Instead, he sprinkled something called ‘sulfa powder’ on it, and it cleared right up. It was a miracle!”
“I bet it was. There were fewer antibacterial medications then; and because they were so new, the infection-causing bacteria had not yet developed resistance to them. It was good news in 1940, but now fighting many infections has become more difficult. So what else was going on then other than World War II in Europe and Jack Benny (who was that?) on the radio?”
“I recall Mrs. Arnold telling about traveling with her three children. They all became ill and needed medical attention. She told the physician that her husband was a doctor, and the physician felt obligated to treat the family without charge. It was called ‘professional courtesy,’ and then it was offered routinely. It is not as straightforward now because of legal (Stark anti-kickback laws) and insurance issues.”
“You are still making things sound pretty good in 1940, Curmudge. Other than the physicians’ limited armamentarium (see, Curmudge, I finally learned that word), there must have been some things that weren’t so great about primary care during your childhood.”
“When I was much younger, it was common for a person to become ill and die while under the care of just his primary care physician. Now in the U.S., except for extremely isolated locations, a seriously ill person is promptly referred to the appropriate specialist. The patient often studies his illness and becomes involved with more than a single caregiver in developing his plan of care.”
“I guess medical care was not always as transparent as it is now.”
“Right, Julie, and that could have been a problem in the past when medicine was often practiced in patient-one-doctor isolation. If your primary care physician had the knowledge and personality of a Marcus Welby, you experienced positive, personalized care. In the hypothetical case of a physician who was so confident of his abilities that he would not entertain discussion with anyone about alternate approaches or a second opinion, the patient would be at risk. That would certainly be the case when the physician made the statistically almost-inevitable error in diagnosis or treatment.”
“That sounds scary, Curmudge, especially when you consider that nobody is perfect.”
“The problem is compounded, Julie, when the patient as well as the physician carry the old-time image of the infallible doc. The patient says, ‘It’s okay if the doctor says so,’ and then abdicates all decisions to the physician.”
“So what do you do if the patient in this situation is your aged parent?”
“You intervene, if possible. But that’s a different story.”
“I have the feeling, Curmudge, that this is one of those very rare occasions when you know what you are talking about.”
“In this blog even the hypothetical cases are true. The only things fictional are you, Jaded Julie, and I, Kaizen Curmudgeon.”
Affinity’s Kaizen Curmudgeon
Thursday, August 27, 2009
Thursday, August 20, 2009
Primary Care in 1940
“Okay, Curmudge, who cares about health care in 1940, and what does it have to do with Lean?”
“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”
“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”
“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”
“It sounds as if your town lived life in the slow lane.”
“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”
“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”
“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”
“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”
“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”
‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”
“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”
“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”
“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”
“So, senescent sage, how can physicians today achieve this elusive personalized care?”
“I’ll conjure up a vision, Julie, and share it with you in a week or two.”
Affinity’s Kaizen Curmudgeon
(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.
“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”
“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”
“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”
“It sounds as if your town lived life in the slow lane.”
“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”
“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”
“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”
“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”
“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”
‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”
“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”
“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”
“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”
“So, senescent sage, how can physicians today achieve this elusive personalized care?”
“I’ll conjure up a vision, Julie, and share it with you in a week or two.”
Affinity’s Kaizen Curmudgeon
(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.
Friday, August 14, 2009
Lean Success Stories--the Charge Capture Project
“Jaded Julie, I think it’s time for us to share some success stories.”
“If these ‘Curmudgeon Chronicles’ really do depict success, I can be certain that they won’t be autobiographical.”
“Don’t be disparaging, Julie. For some senior citizens, just getting out of bed in the morning is a success story. But we want to talk about how implementing the Lean culture and using Lean tools led to process improvements right here at Affinity. These stories will be told by the people who did the work and made things happen, or you and I will tell the story for them. We’ll start with Deb Voyles and her charge capture project.”
“Okay, Curmudge, just what is ‘charge capture,’ anyway? You know that I can’t understand the story unless I learn the language.”
“A person’s hospital bill is the summation of the charges for each treatment or service performed for the patient. This cannot be done correctly unless each service and its duration are recorded on the patient’s chart. These data are then transferred to a charge sheet, given a billing code, and sent to Patient Billing. If any step in this process is overlooked, the bill will be low; and the hospital will not receive its full payment from Medicare, the patient’s insurance, or the patient himself.”
“So what was the problem?”
“The nurses considered the charge capture process to be extra work. Their job was to care for the patients, not collect money. When Deb met with the nurses to plead for their cooperation, they—to use a common phrase—just blew her off.”
“Very frustrating! But we wouldn’t be talking about this if it hadn’t somehow become a success. What—and who—turned the process around?”
“The economy went south, Affinity instituted a margin improvement hoshin, and the hospital president provided the support necessary to put the charge capture project in high gear. Deb Voyles was appointed project leader with Stan Shelver co-leader to aid in communication and provide a director’s ‘inspiration.’ Carol Jansen was Lean facilitator. A ‘charge specialist,’ the unit clerk in each patient care unit, was designated; a new FTE was created in each emergency department to fill that roll.”
“Okay, Curmudge, we’ve got the team. Now what?”
“The first step was to change the prevailing mindset about charge capture. Deb did that by looking at charts from the previous month, computing the ‘forgotten charges,’ and posting the results on each patient care unit in the nurses’ break room.”
“That sounds like visual management. Good move!”
“She followed that up by meeting with the staff of each patient care unit to explain the financial impact of the forgotten charges and to demonstrate the effectiveness of utilizing the Universal Chargesheet. Stan joined Deb at the meetings and ‘encouraged’ the staff to begin using the new chargesheet.”
“Curmudge, as an old chemist like you would say, ‘Management provided an essential catalyst.’”
“Twice weekly, Deb would meet with charge specialist staff, training them on effective charge capture, and addressing charge issues. She made herself available to them 24/7 (via phone and email) to answer charge capture questions. The specialists would track the additional charges they found using the new charge capture process. They posted these results every week in the break room. At the end of the first month, Deb was able to pull the financial data from the monthly finance reports. She created a chart that compared the revenue per patient from the previous month to the current month. These charts illustrated the success of the new charge capture process and were posted on every patient care unit every month. The staff responded with enthusiasm, and the charge capture project gained momentum. Deb’s weekly meetings with the charge specialists became less focused on training and more focused on reviewing new procedures to develop charges. She saw a new culture emerging at the hospitals. It was exciting!”
“There is, of course, more to the story.”
“Deb continued tracking their success on a larger scale in which last year’s charges (with money left on the table) were compared with this year’s (with all charges properly captured). The three-month trial yielded a 40% increase in revenue capture per patient.”
“That undoubtedly attracted people’s attention.”
“It’s like our Flywheel posting on 3/26/08, Julie. One person with enthusiasm and determination was needed to get the project moving and to attract others to the effort. That was Deb Voyles.”
“Curmudge, despite this project’s resounding success, it didn’t seem to require many of the classical Lean tools.”
“You’re correct, Julie. The project was well defined without needing value stream mapping. It had abundant top-level support, extraordinary leadership, a team with accelerating enthusiasm, and a result that should be enduring. One essential Lean tool was visual management. Perhaps we should summarize by saying, ‘All’s well that ends well.’”
“You’ve got that right, Mr. Shakespeare.”
Affinity’s Kaizen Curmudgeon
“If these ‘Curmudgeon Chronicles’ really do depict success, I can be certain that they won’t be autobiographical.”
“Don’t be disparaging, Julie. For some senior citizens, just getting out of bed in the morning is a success story. But we want to talk about how implementing the Lean culture and using Lean tools led to process improvements right here at Affinity. These stories will be told by the people who did the work and made things happen, or you and I will tell the story for them. We’ll start with Deb Voyles and her charge capture project.”
“Okay, Curmudge, just what is ‘charge capture,’ anyway? You know that I can’t understand the story unless I learn the language.”
“A person’s hospital bill is the summation of the charges for each treatment or service performed for the patient. This cannot be done correctly unless each service and its duration are recorded on the patient’s chart. These data are then transferred to a charge sheet, given a billing code, and sent to Patient Billing. If any step in this process is overlooked, the bill will be low; and the hospital will not receive its full payment from Medicare, the patient’s insurance, or the patient himself.”
“So what was the problem?”
“The nurses considered the charge capture process to be extra work. Their job was to care for the patients, not collect money. When Deb met with the nurses to plead for their cooperation, they—to use a common phrase—just blew her off.”
“Very frustrating! But we wouldn’t be talking about this if it hadn’t somehow become a success. What—and who—turned the process around?”
“The economy went south, Affinity instituted a margin improvement hoshin, and the hospital president provided the support necessary to put the charge capture project in high gear. Deb Voyles was appointed project leader with Stan Shelver co-leader to aid in communication and provide a director’s ‘inspiration.’ Carol Jansen was Lean facilitator. A ‘charge specialist,’ the unit clerk in each patient care unit, was designated; a new FTE was created in each emergency department to fill that roll.”
“Okay, Curmudge, we’ve got the team. Now what?”
“The first step was to change the prevailing mindset about charge capture. Deb did that by looking at charts from the previous month, computing the ‘forgotten charges,’ and posting the results on each patient care unit in the nurses’ break room.”
“That sounds like visual management. Good move!”
“She followed that up by meeting with the staff of each patient care unit to explain the financial impact of the forgotten charges and to demonstrate the effectiveness of utilizing the Universal Chargesheet. Stan joined Deb at the meetings and ‘encouraged’ the staff to begin using the new chargesheet.”
“Curmudge, as an old chemist like you would say, ‘Management provided an essential catalyst.’”
“Twice weekly, Deb would meet with charge specialist staff, training them on effective charge capture, and addressing charge issues. She made herself available to them 24/7 (via phone and email) to answer charge capture questions. The specialists would track the additional charges they found using the new charge capture process. They posted these results every week in the break room. At the end of the first month, Deb was able to pull the financial data from the monthly finance reports. She created a chart that compared the revenue per patient from the previous month to the current month. These charts illustrated the success of the new charge capture process and were posted on every patient care unit every month. The staff responded with enthusiasm, and the charge capture project gained momentum. Deb’s weekly meetings with the charge specialists became less focused on training and more focused on reviewing new procedures to develop charges. She saw a new culture emerging at the hospitals. It was exciting!”
“There is, of course, more to the story.”
“Deb continued tracking their success on a larger scale in which last year’s charges (with money left on the table) were compared with this year’s (with all charges properly captured). The three-month trial yielded a 40% increase in revenue capture per patient.”
“That undoubtedly attracted people’s attention.”
“It’s like our Flywheel posting on 3/26/08, Julie. One person with enthusiasm and determination was needed to get the project moving and to attract others to the effort. That was Deb Voyles.”
“Curmudge, despite this project’s resounding success, it didn’t seem to require many of the classical Lean tools.”
“You’re correct, Julie. The project was well defined without needing value stream mapping. It had abundant top-level support, extraordinary leadership, a team with accelerating enthusiasm, and a result that should be enduring. One essential Lean tool was visual management. Perhaps we should summarize by saying, ‘All’s well that ends well.’”
“You’ve got that right, Mr. Shakespeare.”
Affinity’s Kaizen Curmudgeon
Thursday, August 6, 2009
Information at Your Fingertips
“Despite what you read, Jaded Julie, health care is a lot better than it used to be.”
“So, Curmudge, is that your professional opinion?”
“Nope, it’s my conjecture. That’s a better word for a fictional person. Consider this example: When I was a kid 70 years ago, the doc-with-the-black-bag couldn’t drag around a medical library when he made a house call. When he encountered a patient with unfamiliar symptoms—me—he could only rely on his experience, or as we say now, he had to ‘wing it.’”
“Since you are still with us, I congratulate your parents on their choice of family physician.”
“Fast forward to the present. Everyone knows about the power of CT’s and MRI’s for diagnosis, but I was curious about what is available in the readily accessible literature.”
“By ‘readily accessible,’ Curmudge, you mean just a couple of mouse clicks away.”
“Exactly, and I found a ton of stuff for physicians, midlevel (advanced practice) providers, nurses, pharmacists, and people writing about health care. Some of these are available only by purchase, such as the Isabel Diagnosis Reminder System (1) and several from Wolters Kluwer Health [5-Minute Consult Database, Drug Facts and Comparisons®, Evidence Based Guidelines, Lippincott’s Nursing Procedures and Skills, and several others] (2). The Institute for Clinical Systems Improvement has order sets and algorithms for diagnosis and treatments available on their website (3). Closer to home, we have Affinity policies and preprinted or standing orders for hundreds of diagnoses, evidence based treatments, and procedures. To obtain this treasure trove, I just talked with a few people and rummaged around in Google. Just imagine how much more could be obtained with a literature search done by the St. E’s or Mercy library.”
“Now I know why you were huddled with your computer for the past two weeks. So what good is all this?”
“The physician with his handy computer or personal digital assistant will no longer have to ‘wing it.’ If necessary, he can check a diagnosis or medication during the patient encounter or perhaps after the fact to confirm his decisions and monitor the quality of care he provides (4). Nurses and managers can use the evidence based procedures in these resources as the basis for standard work in any of the patient care areas of the hospital.”
“I understand, Curmudge, that we are already using the preprinted orders in our hospitals. Their check-the-boxes feature serves to remind the physicians of the latest evidence based therapies. When a physician overrides a pre-checked box, it must be justified. These forms also minimize variations in provider prescribing practices and critical aspects of patient care.”
“That’s it, Julie. I hope you now agree with me that health care has improved over the years.”
“Curmudge, you were fortunate to have survived old-time medicine, but I suspect that was not always the case.”
“Here’s another personal example: The same doctor who used his vast experience to cure me of gosh-knows-what in the 1940’s also brought my mother into the world in 1899. He was at the bedside of her mother who died of gosh-knows-what in 1902. So my mother, at the age of three, lost her mother and I lost a grandmother that I never knew.”
Affinity’s Kaizen Curmudgeon
(1) http://www.isabel.org.uk/pdf/Product_Release.pdf
(2) http://www.clineguide.com/Common/PDF/ClineguideMobileReleaseFinal.pdf
(3) http://www.icsi.org
(4) http://www.ama-assn.org/amednews/2009/06/29/prsn0629.htm
“So, Curmudge, is that your professional opinion?”
“Nope, it’s my conjecture. That’s a better word for a fictional person. Consider this example: When I was a kid 70 years ago, the doc-with-the-black-bag couldn’t drag around a medical library when he made a house call. When he encountered a patient with unfamiliar symptoms—me—he could only rely on his experience, or as we say now, he had to ‘wing it.’”
“Since you are still with us, I congratulate your parents on their choice of family physician.”
“Fast forward to the present. Everyone knows about the power of CT’s and MRI’s for diagnosis, but I was curious about what is available in the readily accessible literature.”
“By ‘readily accessible,’ Curmudge, you mean just a couple of mouse clicks away.”
“Exactly, and I found a ton of stuff for physicians, midlevel (advanced practice) providers, nurses, pharmacists, and people writing about health care. Some of these are available only by purchase, such as the Isabel Diagnosis Reminder System (1) and several from Wolters Kluwer Health [5-Minute Consult Database, Drug Facts and Comparisons®, Evidence Based Guidelines, Lippincott’s Nursing Procedures and Skills, and several others] (2). The Institute for Clinical Systems Improvement has order sets and algorithms for diagnosis and treatments available on their website (3). Closer to home, we have Affinity policies and preprinted or standing orders for hundreds of diagnoses, evidence based treatments, and procedures. To obtain this treasure trove, I just talked with a few people and rummaged around in Google. Just imagine how much more could be obtained with a literature search done by the St. E’s or Mercy library.”
“Now I know why you were huddled with your computer for the past two weeks. So what good is all this?”
“The physician with his handy computer or personal digital assistant will no longer have to ‘wing it.’ If necessary, he can check a diagnosis or medication during the patient encounter or perhaps after the fact to confirm his decisions and monitor the quality of care he provides (4). Nurses and managers can use the evidence based procedures in these resources as the basis for standard work in any of the patient care areas of the hospital.”
“I understand, Curmudge, that we are already using the preprinted orders in our hospitals. Their check-the-boxes feature serves to remind the physicians of the latest evidence based therapies. When a physician overrides a pre-checked box, it must be justified. These forms also minimize variations in provider prescribing practices and critical aspects of patient care.”
“That’s it, Julie. I hope you now agree with me that health care has improved over the years.”
“Curmudge, you were fortunate to have survived old-time medicine, but I suspect that was not always the case.”
“Here’s another personal example: The same doctor who used his vast experience to cure me of gosh-knows-what in the 1940’s also brought my mother into the world in 1899. He was at the bedside of her mother who died of gosh-knows-what in 1902. So my mother, at the age of three, lost her mother and I lost a grandmother that I never knew.”
Affinity’s Kaizen Curmudgeon
(1) http://www.isabel.org.uk/pdf/Product_Release.pdf
(2) http://www.clineguide.com/Common/PDF/ClineguideMobileReleaseFinal.pdf
(3) http://www.icsi.org
(4) http://www.ama-assn.org/amednews/2009/06/29/prsn0629.htm
Thursday, July 30, 2009
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
“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 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.
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