Friday, November 2, 2018

Working Smarter, Not Harder

Our hospital is a very complex system. What happens in one area of the hospital can have a major effect in what happens in another unit or department. Because of this complexity, it is difficult to maximize our efficiency such that no one is waiting to move to the appropriate place.

I have written in this blog before that we are students of flow. We are designing our systems and matching the demand for services with the supply of caregivers throughout our organization. When we design our systems, hold ourselves accountable to the design, and match capacity to demand, our patients move one at a time in beautiful choreography. This is called single patient flow. On the other hand, when we have no design or don’t follow our designs and rely on hard work alone, we frequently have patients stuck in a bottleneck.

Humans can overcome bottlenecks by working around them or exerting more pressure or influence to get through them. This is known as expediting. An example of expediting is when we take someone away from their usual work to complete a task that the people who normally do it cannot accomplish. An example would be having a housekeeping manager race to clean a room because many dirty rooms have been called in for cleaning at once in the early evening. Rather than fixing the root cause of the problem, in this case the batching of discharges, we send someone to work around the problem in the moment to get the patients what they need. We have improved patient flow, but we will need to fix it again the next day because the batching of discharges has not been fixed. Smart leaders will learn the cause of the bottleneck, redesign the system, and not become complacent with the short-term success of expediting.

We know about the Hawthorne Effect as well, that when a problem gets focused on, it usually gets better without anyone redesigning anything. This is generally because the people involved, knowing that their work is being studied, work harder and faster to overcome the poorly designed process. This is the reason why we are so focused on getting the work redesigned first before we celebrate what looks like an improvement. If the gains are due only to shining the light on the problem, we lose the gains as soon as the light is turned off.

Our flow team and our Emergency Department leaders have been spending time studying and redesigning our processes to move admitted patients out of the Emergency Department to an inpatient bed as soon as possible after the decision to admit has been made. This system is very complex, and it has many sub-systems. The ED physician must enter the admitting order, a bed must be identified as empty on the appropriate unit, and then it must be cleaned. The ED nurse must communicate with the receiving nurse, as does the ED physician with the receiving physician. Transport must be notified and arrive to move the patient.

The number of patients waiting in the Emergency Department to be moved to an inpatient bed at 7 p.m. is a metric on the Executive Lean Daily Management Board. Every morning, we review this metric to learn the reasons that patients are waiting. Much progress has been made through system redesign and I am so proud of all involved. And while we still have processes in need of further improvement, we are working smarter rather than harder. Take a look below at the results of their hard work.

Patient Engagement Question — Wait Time in ED Before Admitted (Quarterly)


  1. Does ED RN to IP RN phone report cause a bottleneck during the admission process? Is there a way that we can implement a report sheet through EPIC in order to do away w/ the phone report?

  2. I have learned a while ago that great ideas do not come in “Eureka !” moments, but start brewing when different perspectives and experiences are brought together under the same roof, around a meeting table, or in the same blog. Therefore, I will share with you a different view on the issue of patient flow: as it unravels in the outpatient settings, more specifically at GBMC at Owings Mills.

    About 4 years ago, in response to the patients’ complaints of not being able to reach us with urgent issues, we instated the “walk-in” service. For acute, not life-threatening matters, our patients could now walk in, Monday to Friday, 7-11 AM, and they will be seen by one of our providers, on a first come, first served basis. The project took flight rapidly, and led to an increase in Press Ganey scores and decrease in ER and urgent care visits, while decreasing the amount of phone calls received by the practice.

    We were the first office to establish this service and remain the last one standing.
    As the practice got bigger and the number of patients walking in increased, the patient flow is becoming chaotic at times. The overcrowding of the waiting room (particularly with the flu season approaching), sometimes having to close the service before the advertised 11 AM, and to turn some of the sick people away, these are not only issues of liability, but are things that I do not wish to happen to my dear ones.

    So, as you said, Dr Chessare, its time to get the work redesigned again. We started brainstorming on it. How do you control the masses? I saw it with my kids at Disney World (How many rides does one wait in line before he learns to get a Fast Pass? ) and I see it when I get their hair cut at Great Clips (I sign in from home, through their app, and I know how long the wait time is, so I can pace myself).

    I hear that some urgent care centers have a similar approach. Can Epic do that? I’d like to have an IT specialist at our brainstorming table.

    Well, anyway, this is how far we’ve got. I know our problem is totally different from the issues that the hospital is facing, but the great ideas germinate in casual conversations, so I thought it’s worth sharing.

    1. Thanks, Dr. Ghiaur. I am so grateful that your team, led by Dr. Ferentz is working to design a system to best meet the needs of your patients. Walk-ins can work if you start by calculating the rate of walk-in arrivals and match this demand to the supply of caregivers. You may want to assign a physician or advanced practitioner to seeing only the walk-ins. If it turns out that your no-show rate approximates the walk-in rate, then you might be able to do it without assigning someone. It is clear that walk-ins don’t work if we just expect clinicians with full schedules and very few or no “no-shows” to see them. Every system is perfectly designed to get the results that it gets!

      Thanks for using science and logic to redesign your system!

  3. Thanks, Josh B. We don't want to eliminate 2-way communication between the nurses because this is safer. An in person handoff is the best but the phone also works.


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