THREE CORE BELIEFS I. CONTINUOUS IMPROVEMENT

EVERY WEEK

EVERY DAY

EVERY HOUR OF EVERY DAY

Here is the first of three core beliefs for excellent hospital operations which are lived every day by the successful hospital executive. They appear common, but are not commonly practiced. It is in the details you will see a road map for success.

1. Continuous Improvement

Continuous Improvement programs have caused the early demise of many great ideas. But it isn't entirely their fault. There is no end to passive collection of data, no point where the case is airtight where there is no leadership. When the leader is not willing to say "we must move forward" how can a decision ever be reached? What progress can be expected?

How much data do you need? One patient who has not been served well is all the analysis you need, if their experience is rightly understood.

It is a great challenge for any leader to set a firm target, and make a job assignment to everyone to participate. It takes a lot of guts, faith in answers you don't have yet, and willingness to do some hard work collaboratively through the whole process.

It takes character to offer amnesty for past performance, praise for noble failures, open praise for success, and sanctions for inaction. It takes a leader to hold above everyone, every interest,  the mutual best interest of the targets for improvement. Targets deserve that spot if they are mission-driven. They will align all interests in time, if leaders publicly set them first, and privately adhere to them consistently.

That is no simple task. Open praise of a few makes criticism, even in private,  intolerable to the rest. And it is not uncommon that in many organizations open praise is also intolerable.

It is the effective executive who says "this is new. We will be making a few mistakes, but it is necessary, and I shoulder the responsibility with you. We will all learn together. The success of any one of you will really be the success of all of us, so long as we are always working to help each other deliver better care.

"You have responsibility, visibly, and so do I. I don't have the answer. I have absolute faith we will discover it through effort together. I ask you to join me in holding that faith in our future and in working with me to build it. Since I don't have the road map we will need to work together. And I will do whatever I can to help you help us all.

"Therefore, it is now a part of your daily job to help discover, design, test, refine and fully implement the solutions that will move us forward. Make it your routine. We must achieve this target this year for the sake of this community. That is my commitment and my responsibility to you as well. It's my job too. I'll be there when you try and fail. I'll be failing with you. And we'll be learning, not failing, together.

"Give me your best failures and we will never fail. We'll all grow together.

"The only real failure is inaction.

"If you want to criticize because you are willing to try something new, something better, I'm with you. If you criticize and have no answers and aren't putting in the time and effort to develop them, then instead of criticizing try something new and you may learn a better answer.

"The secret to good teamwork is to go along with things that you think are good, even if they aren't quite as good as your personal idea. Support them, own them as if you think they are perfect. Get behind good ideas and back them up, sell them, and put out effort to make them work. Every idea needs enthusiastic supporters and tireless builders, refining the answers all the time: Real Progress Engineers.

"The problem of bad teamwork is criticizing a good idea because it isn't perfect or it isn't yours. These are what I call the only real failures - lack of teamwork, lack of action, or action that is undermined.

"If you go along with it, it IS your idea and you can share in the success, and no one will care about who actually came up with it. Who gave that person the idea? Who knows? Everyone owns it.

"The rest of the things we used to call failures are now learning experiences. What did you learn? What are we going to try differently? Many good things that failed can work with a little tweeking. I don't want to lose those things just because they need a little grammar, a little English, a little polish and a little time.

"I'll be there when the smallest efforts succeed, to say "Thanks" and to let everyone know what you have done for the life of a patient, for the well-being of their family and the future of our hospital. Let's get started..."

Continuous Improvement is a commitment to a vision and a concrete set of targets made public first and foremost by the Leader; a commitment of continuous attention to operational excellence, quality and service by the top executive and all management every week, every day, every hour of every day.
 

Have you really seen me? The Power of Patient Observations

It is eye-opening to discover how much patients are not actually seen or understood in their stay in the Hospital. People are focused on their work, so in retrospect it makes sense. But if you stand outside of any particular job and just watch a patient for a couple of hours in the Emergency Department, or on an Inpatient Unit, or in a Clinic or Same-Day Surgery you will discover many things. Some very positive and affirming: people are healing patients all the time. And some of those things will be negative - opportunities for improvement.

When an executive spends the time to do observational work they are saying to the entire organization "It's better to open our eyes, even though we will discover some things aren't working, then to close our eyes and say conveniently, but untruthfully,  'mission accomplished'".

This chart is a simple method of illustrating a patient's experience during a period of two or three hours in any location in the Hospital. In the particular example here, this is a patient's three-hour stay in an Emergency Department. Each slice of color represents a period of time. The color coding is described at the bottom from left to right in the order in which it occurred. You can click on the chart for a larger full-size version easier to read or to print.

The patient walked in the door at nine AM. Without any delay at all, they were Triaged and registered. The Triage process was very fast, but the registration process took a little time.

The patient was taken to a room in back immediately after their registration (green) and began waiting in their treatment room. This first waiting period is illustrated as the first red block to the far left. Throughout the chart all patient waiting time is shown as red.

This patient had stomach pains, and did not require admission to the hospital. Most emergency departments would view a three hour length of stay as great. And in many ways it is. But not necessarily for an outpatient. 90 minutes is good for the outpatient.

There are several stages of work involved. Note the MD assessment in yellow. That actually took place in the last third of the visit. The patient spent nearly two-thirds of their visit just waiting. During that waiting time some work occurred - lab orders, MD / RN reviews and communication, phone calls, gathering materials / medications, etc.... However, the patient sat for just over an hour without anyone entering their room to keep them informed. From their perspective, this was all just waiting delay. This was during a very tense time for the patient, so that hour could well have been an eternity.

And much of that red time was delay for the staff as well: items waiting to be attended to, or not available when needed, etc....

We interviewed the patient at the close of their stay. They were very appreciative, but did mention that the delay was not a positive experience for them. They were worried and were unsure how serious their symptoms were. They became even more anxious, thinking the medical staff were trying to figure out what was wrong, and that maybe no one really knew. And no one could tell them until just near the very end of the stay, almost two hours into their visit.


As mentioned above, three hours is not long for an inpatient ED admission, but it is long for an outpatient. If you are in pain or worried, without proper care, teaching, attention, ten minutes can be a lifetime in hell. And nearly two hours waiting in back is not ideal care.

Here was a hospital that had already gone through a major lean initiative, and another Patient Satisfaction / Management Coaching initiative to 'hard-wire' improvement. The commitment to excellence was well established, so we heard.

These programs taught "continuous improvment" in their words. But in their structure of a single phase of discrete one-time process and management changes, they were actually teaching "one-time fix" behaviors.

Any interest at all in going back to observe patients or the flow again was the last thing on most folks' minds. They had been "improved" and didn't want to go back there. For them, continuous improvement was really a sign of failure.

Their words were "We believe in Continuous Improvement" but their actions were "We're already done with that. We won't be going back there again. Why would we?"

How well did these other improvement programs serve the hospital, if the culture, at the close of the project, was a culture of "we're done" "we're excellent enough" "we don't need to nor want to look anymore at that?" "Patient care? Mission Accomplished!"

Yet, the job was not done. The consultants were done, but the job wasn't really done, and certainly not 'hard-wired'.

Indeed, the notion of ''hard-wired' or 'made to last' speaks to the idea of the turn-key operation: That it can be done once and for all,  like buying a new car. But according to Tom Peters in Re-Imagine! this thinking is wrong: really exceptional performance must be built and re-built every day with great care and creativity,  and no one can proscribe exactly how it must look. Vigilance and observation do not end. They become part of everyone's personal practice, personal approach to seeking feedback; seeking to stay close to the patient's experience. And they use that constant flow of new information personally gathered to discuss, to brainstorm as they work, in the department, in real-time.


Peter Drucker wrote about this over fifty years ago in The Practice of Management. By the time  performance metrics are quantified into a nice report, they are obsolete. They can only confirm that you have managed well, but cannot guide you. For that, you must gather your own handful of information every day directly, and that in collaboration with the people you work with.

You cannot "hard-wire" living systems, and if you really try to, it becomes a barrier, an impediment to true excellence. That is why nobody wanted to look again. They thought it was now "hard-wired". However, because excellence is a flow of energy, ideas, teamwork and creativity, a process of self-examination and observation, a human process of collaboration and change, a living process, it cannot be nailed down into something fixed, or done, so that others feel it is "mission accomplished" and can turn away to other things.

There is something uncomfortably open-ended about real excellence. But many thrive on the adventure.

 "Systems" become obsolete very quickly in a truly exceptional operation. New methods and philosophies are developed all the time because no matter how good it was, people want to do better. It is a 'hard wired' realization to see that there is no standing still. You cannot maintain. You can move forward, and if not, the hospital slips backward.


"Maintaining" the number one position requires continuous effort. It doesn't end. It must be made, constructed, built every day again. And that is because in a Hospital, excellence is care, and care is human performance.

It won't look the same every day, or for every patient. To reach and live a core set of  values means, paradoxically, not doing it the same way. Customization, adjusting for the patient. Listening. It is always new. That is the difference between life and death to an organization or a human being.

Rather than "hard-wire" why not think about "liberation" of the organization? Rather than think of the Hospital as some giant machine, why not think of it as a living entity always poised to take the next step in personal growth? Why not?

But a living being needs nurturing and feeding, and sometimes they don't turn out just as you might like.

Innovation is far more powerful than any machine.

Nowhere is this distinction between living in the flow of excellence and living in a retrospective hard-wired "system" most in evidence than with 'rounding'. When we have watched folks "round" after having earned a "black belt" in rounding, we see they are hitting the points on their checklist, but missing obvious things staring them in the face. They talk to the patient but stop noticing that the nurse hasn't washed her or his hands or used the hand sanitizer. They ask the patient questions, but do not stop to watch a nurse and a patient interact with each other, nor to give good praise or feedback when such interactions happen to take place in front of them. They don't ask the nurse "How are YOU doing today? How is the work flow for you?" They don't stop and brainstorm for a solution right there. And many a tired nurse has been simply overlooked by the exec doing rounding. They are trying to get through their "rounding" responsibilities. And that is what they are doing - going through the motions. But they aren't actually rounding.

Try telling an Olympic Athlete that your training exercises to help them swim, or run, or jump are so good they will not actually need to swim, jump, or run again! That is the chimera of "lean" and "hard-wiring" promises. Once you "hard-wire" anything, people stop thinking about what they should be doing; people stop looking around to see what is going on; people rely upon the "system" now because it has already been built, in the past tense; and so in the 'present tense' they just go through the motions of that "system" just like they did the last system. No Olympic Athlete could get away with that.

Emergency Department Door to Physician Treatment Under 30 Minutes ... NOW!

Door to MD / Door to Mid-level Treatment Time Simple Sampler

Statistics Shmatistics!

Got a watch? Can you count to ten? Like INSTANT results?

Want your Emergency Care Door-to-MD / Mid-level Treatment time down to BELOW 30 minutes RELIABLY, or your Urgent Care Door-to-MD/ Mid-level Treatment under 15 minutes?

Why measure it and "wait for the data" when you can

SEE IT!

TRACK IT!

and F I X   I T !

at THE SAME TIME?

Such a deal!

POSTED EMERGENCY ROOM WAITING TIMES ARE OFTEN FAKE

We have seen a recent trend in Emergency Services and that is posting waiting times on billboards, or the Hospital's internet front page that are very short - 20 minutes, 15 minutes, 10 minutes.

When we dig into the data, we find that the traditional standard measure of Door to Treatment (that includes Patient entrance into the waiting area, greeting, registration, triage [in Waiting Area or at bedside], Caregiver Assessment/Teaching, initial lab draws, MD / Mid-level reviews chart and then MD / Mid-level enters room, assesses and begins Treatment) is not actually being used. A new measure has been created. The traditional measure was called Door to MD / Mid-Level Treatment.

And the new measure is called "Waiting Time to Being Seen": But not necessarily seen by the MD or Mid-Level. Sometimes it is "waiting time to be seen" by a greeter or clerk. When it is an MD, Mid-Level or RN, it is not necessarily "waiting time to be seen" for actual Triage and Clinical Assessment; often it is nothing more than "being seen" by an RN, Mid-Level or MD passing through the waiting area, or initially greeting the patient at the front desk. No actual history, assessment or anything that could legitimately qualify as clinical work is being done at that point where this "waiting time" is proclaimed as over. 

The actual formal clinical Triage assessment is still later in the process. And the additional waiting time to get there is now hidden from the claimed metric for "waiting time".

Furthermore the "waiting to be seen" metric doesn't always begin at the door. Originally, the "Door to MD / Mid-Level Treatment Begins" started when the patient first entered the door of the waiting area or the Emergency Trauma entrance of the Hospital.

The new metric doesn't start at the door. Now the starting point for this time measurement begins when the Registrar enters the patient's information into the computer, and that is generally when the patient is registered.

That happens after the patient has walked in the door, and after they have waited often at the end of a long line to speak to the registrar. Or simply waited for some time until a registrar or RN returned to the waiting area desk. Is this really the fair starting point for the patient's experience? No. The starting point is the moment they open the door and walk in or are rolled in.

A great deal of actual waiting time has been hidden from this highly touted new statistic, making it misleading.

But it makes the waiting time to RN, MD or Mid-level, indeed the entire Emergency Deparment Length of Stay look much better than it actually is!

Yes, metrics can be faked and often are.

These are all part of cutting corners on the metric to make the numbers look better because they are not actually part of making the flow more efficient for patients.

These times are not Door-to-MD / Mid-Level Treatment times according to the standardized, traditional  metric.


DIRECT-TO-BED DONE WRONG MAKES THINGS WORSE

Some hospitals do bring patients directly to the bed in back when there is an empty and staffed bed, and this is a great strategy to reducing waiting time and potential medical error. But only so long as the RN completes the Triage work, initial labs, assessments and immediate interventions that are all part of the appropriate clinical pathway IMMEDIATELY when the patient is brought back. This expedites the MD /Mid-Level entering the room sooner to make their full assessment and begin formal intervention.

But Direct-to-Bed alone is not a fix and in isolation can make things worse, adding delay, neglect and medical error because, as we have seen, this can be used to warehouse a patient in the back where they are now isolated and still don't get rapid treatment. 

Indeed, in some cases delays got longer, and clinical issues arose from those delays because the waiting room looked empty; the patient was now "out of sight - out of mind"; and no one really knew that the patient waiting in an Emergency Room bed in back hadn't yet been seen by RN, MD or Mid-level. 

In fact, once they were placed into a bed in back, their actual status became a mystery - they fell into a crack in the process that looked on the tracking board like they were being assessed and treated, as though they had been seen by the RN but "seen" and "treated" are two different things - so the patient fell into a void, a twilight zone. On the tracking board, they were in a bed with an assigned nurse, maybe even seen by her or him so it looked like something was going on. But the RN assigned to that bed had not actually taken the assignment of that patient.

This is the problem with popular solutions that are not made in concert with actually changing the responsibilities, competencies, teamwork and communication points, but merely fixing the physical flow, or mechanically and mindlessly tracking data points in the computer.

Rather than fix the actual problems, some Hospitals have found a way to dissimulate (nice word for fibbing or misleading) by cutting corners on what they actually report as "waiting time". They compromise the original intention of waiting time: How long does the patient have to wait before their treatment begins? Door To Treatment!

In our discussion today, we aren't talking about the fake "Waiting Time in Our Emergency Department waiting Room" metric that some hospitals brag about and even post on bill boards and on the internet. 

We are here talking about the real thing: The time from when the patient opens the door to enter the building to the time the MD or Mid-Level begins treatment.

And that time can be and is well under 30 minutes in the top performing hospitals - even in complex Trauma Centers that are also university teaching hospitals - such as Duke University Hospital - a shining example of this level of performance.


How can you take that next step in the journey of your own Emergency Department?

You can learn from the stuff we did with Duke and other Number One Hospitals:

SEE THE FLOW - BE THE FLOW

FIRST ROUND!

Every twenty minutes the manager (yep, not the Charge at first, but the MANAGER or even the DIRECTOR - Hey, this is your home, right?) rounds through the waiting room and notes what is going on. Did I say this was permanent? No. Not every twenty minutes. One day it can be the Charge RN, when you see how valuable this is, how cost effective it is to give them the time to do this.

But you are trying to make human behavioral change, so right now, it's every twenty minutes for a while, at least during the busy hours when waiting time is a problem. And it's the person with management authority and coaching skill to do it. No intermediaries, no layers, no committees. No excuses!

This is the fastest way to make change - data, performance feedback and behavioral coaching and change all at once! So, it's worth the time.

It's Kaizen, baby! 
Rapid Cycle PDCA 
many times a day! 
You'll get it on the way!

A.1. When you go out for the first time and look around, you notice how many folks are in the waiting area, and you look at the log book / tracking report to see how many are waiting over 30 minutes. Maybe you talk with the Triage RN or the Registration Clerk.

B1. And you also note the number of patients waiting 30 minutes or less.

Now you go into the back, into the main ED and post your counts on the White Board for all to see, and make sure everyone you can grab sees these counts and talks with you about them. And each time you round, you come back and post your counts here on the white board, and you notice if things are getting worse or better, and try creating dialogue, interaction, connections, response and understanding: brainstorming on the fly, and innovation right there in your hands. And you are getting more control by asking questions, more effect by giving control to your team. But you won't know where the opportunities are to do this moment by moment unless you become the TRAFFIC QUEEN! (or King!). It's like hall monitor, you can assign the job to anyone, but first get the skills down.

First, it's just positive reinforcement. How did the < 30 minute patients get moved through so quickly? Excellent! Find out now! Let them know you see it. Immediate Feedback! You've got Olympians there, in the rough!

Great performance. This is what you can build upon, so get intimate with it first. See it, discuss it, understand why it works when it does.

Did you even know you had these strengths in your team? If you did, then you haven't learned anything new! Keep looking!

It isn't what you think. It can't be just what you think you know, otherwise you aren't seeing and learning.

You will learn something new. Start by being open to it. It's power, it's a gold mine!


That is what "the moment" really is. Your most powerful tool. Yet everyone knows there is more in the Moment than we can possibly fully understand. So people are afraid of it. It is dangerous to live there. And yet, avoiding it leads to errors, mistakes, poor care and service.

And that is why an addiction to retrospective data is so destructive to managing in that moment, so eviscerating.



And then, you can ask for suggestions around the waiting room times that take longer than 30 minutes.

The first suggestions you will hear may be "We need to spend lots of money.....They - other department - need to do their jobs---."

People may gravitate to the low personal threat answers- low personal change solutions - the ones that don't involve them very much. And therefore the ones almost impossible to make.

The changes that you and your folks can make immediately are not always the ones that will be top of mind. People are looking at other people, not themselves. Or they cherry pick the few  things that are truly out of their control.


When you are there watching, listening, discussing, challenging, praising, questioning every twenty minutes, you will see that the opinions even just a day later are entirely tipped off balance and much less accurate. You will see that just seeing it NOW gives you accuracy you can't get any other way, and it also gives the communication with your staff ACCOUNTABILITY because they can't remember it in a more convenient way. The circumstances are there before you as physical evidence that has not passed into history, not dependent upon mere record. You can see the reality NOW while you can do something about it. And while the others around you can see it too, if you and they are willing to look and acknowledge. You will see that moment-by-moment decisions, habits, skills within the grasp of your own team significantly effect throughput, clinical errors, and the satisfaction of patients, their families, your MD partners, and your staff. 

Finally, you will see that you can cut delays in half by making course corrections on situations that have not yet fully completed: NOW is much more powerful than any sort of data analysis. And it is only in the NOW, in the department, on the floor, in the flow of work, that you can help others make permanent changes in vigilance, in ability to see and understand, in better behavior,  and culture change.


But these are not things that can be easily extrapolated by data. They are largely invisible without direct observation and real-time exploration. Data at best is an accurate shadow reflecting the outlines of what has happened but with little detail - it requires interpretation to understand. Reality in the NOW requires an open mind and willingness to observe, listen, inspect, dialogue. They are things you acknowledge directly because you see them, and things you show and state to others so they acknowledge them, too, instead of ignoring them. "Ignoring them":  code words for ignoring patients.


Praise may open the door, and gentle questions can open the door.

Questions a day later are nearly useless, and much more threatening. Questions about the cause of a problem transform and magnify into implied blame after the fact, and typically result in defensive and less than candid responses.  But in the moment, those inquiries can be put forth in the desire to help, to lend a hand while there is still time to do so. 

Questions about delays, acknowledging delays that are happening now can be greatly fixed now, while everyone is still there,while the process is still happening. And then the whole process was to build teamwork, was to share in the successful resolution and prevention of problems. Now you are handing that success to your team.

What can be done now, with existing resources, with just a little creativity, coordination and teamwork? Just a little leadership in real-time can open up tremendous enthusiasm, creativity and growth.

 SECOND ROUND!

And then you round back so that you are in the waiting area exactly 20 minutes from your first "count". This is where the wrist watch really helps! One with a repeating alarm is really great! Or an Android or iPhone Interval Trainer app can do that for you.

B.2. How many patients that were waiting 30 minutes or less the last time are no longer in the waiting area because they have been admitted to the back? Great!

C. How many patients are newly arrived since your last "count" and have already been admitted to the ED? Super Great!  

You won't see the C patients, but the time has been so short that the registration clerk, or the log or tracking sheet printout will show you.

NEW B.1. How many patients are there that you haven't seen before but are now waiting? These are patients who have been waiting, so far, under 30 minutes.

Now you go back to the white board and post your simple calculation, so everyone can see every twenty minutes during the busy hours, exactly how many patients are waiting, and how many of these are waiting over 30 minutes.

HOW MANY PATIENTS ARE WAITING FOR MD > 30 MINUTES right NOW?




OLD B.1. (B.1. from the prior round count)  Minus  B.2.  =  Patients who are now waiting > 30 minutes.


HOW MANY PATIENTS HAVE BEEN SEEN AT OR UNDER 30 MINUTES DURING THE LAST 20 MINUTES?

B.2. plus C. = Patients who have been seen at or under 30 minutes.

It isn't just the fact that these numbers are posted in real-time that is so important. You are doing this, as a member of management, and discussing this, and trying to figure it out, and maybe fixing it in real-time.  This sets up a whole new culture of accountability and safety, of self-control and empowerment:   to state what is happening openly, respectfully; to ask to collaborate, ask questions, communicate a willingness to help, and a desire to act, with each other,  without fear.

How safe can a Hospital be for a patient if the RN doesn't think she or he has much control over things? That is an unsafe environment. And worse still when the MD thinks like that.

But here you are practicing taking control by asking your own team to communicate with you as a team, to make decisions based on what they see right now, not to ignore it as out of control, but to take the extra step and make something good happen.

What is very important is the fact that you are seeing exactly what is going on to create delay, and intervening where you can, coaching where you can, asking and helping where you can, right there.

All of that flies in the face of the belief, the culture that says "it's out of our hands." It disproves the culture that says "only an expert.... only a committee....only a detailed analysis for months on end..... can fix this": all answers that push change farther and farther away. Unfortunately, that thinking pushes personal responsibility that far away, too. And that belief leads to choices every second of every day in the hospital: bad choices.

At least 50% of most delays are not out of your hands. But to do something about it may mean suggesting something, asking something, directing and prioritizing. It's called being a good Traffic Cop.

When you fix that 50% of the delay, you have power and leverage to go after the delay in other areas, since now there is no excuse for any manager to stay away from their daily operations. You are proving that a manager is only a leader when they do this.


And no hospital, nor the patients in any department needs a manager who cannot lead.

Many years ago many Emergency Departments had great traffic cops, many hospitals had great House Supervisors and Head Nurses, Senior Nuns who did just this sort of thing. They were the great ones. They were the masters of this art of dealing with the fully charged and infinite moment, effectively.

This is an old practice.  Very old. Largely lost. But no change can sustain, nor truly change patient's lives without mastering it.

It requires a willingness to talk about it and ask for help, and step in and give the help as it is taking place, as reality is unfolding. But now folks just want to do it all on their own and in retrospect. Every employee is a silo. They want the world to be boiled down, filtered, photographed and manipulated into their laptop computer, into charts and reports that can be held in hand, put neatly into a folder, kept, used, leveraged. They want to live in a virtual world, which they can master and control.  Every human being is isolated in this way to their own thoughts and the artificial virtual world in their own mind. But in Reality, in the Now, we are part of something bigger. We do not own this world. We participate. But we don't participate effectively if we ignore it, for any reason.

So living in our own personal video game doesn't actually work in a Hospital. And life is better lived in this world, the real one, going forward. The only way to continue to look backward, at data, reports, in retrospect, to our own thoughts, to discussing what is already dead and gone, to dissecting what has no life in it is to turn one's back to the present and the future. Not a good idea.

"Life can only be fully understood looking backward. But it must be lived moving forward."
 - Soren Kierkegaard

TEAM or die!

That's a literal truth in Hospitals!

IN SUMMARY

The first time you round you collect these points of data:

 A.1. and B.1.

Every time you round after the first, you collect these three points of data:

B.2.

C. again

and B.1. again

And on your last round of the day, just collect these data points:

B.2.

and C.

Are you really See'n your Left Without Being Seen?

One of the last things hospital management likes to see are patients who are ill leaving without being seen from  their Emergency Department. And when queried in our ongoing interviews, almost all C-suite executives say the problem is solved, and that their LWBS is at or under the national best practice of 2%.

How can 90% of the Hospitals believe their LWBS is at the best practice level when in truth less than 30% of hospitals perform at this level?  It is the human condition. We need to be unrealistic about ourselves, and our work, often, to keep on going. This is especially with difficult issues, like LWBS. But as you will see, it isn't so difficult.

We find the same with Patient Satisfaction. Most Hospital C-suite executives firmly believe they are operating at 70+ percentile ranking overall.

In the hospitals that have engaged us, we have found that the actual rankings may have hit that mark on a set of specific questions for only a brief time during the prior year. But in the minds of Hospital management, these moments of good news have become generalized to a sense of overall performance.  Yet, when we take a hard look at the actual scores and rankings over the prior twelve months, overall rankings across all questions have always been substantially lower.

We want to believe good things, especially when our work is challenging. Metrics tend to be gathered to support our belief. Or we remember only the times the scores met our hopes and expectations. They are not always independent and objective sources of information.

And when they serve the purpose of helping us feel better, they no longer serve the purpose of guiding us along. How true this is with Hospital metrics, real teachings, and real progress.

The principle behind good, scientific management, is that metrics on human performance can be gathered objectively, to guide performance to real improvement. This is so, but it takes a willingness to re-evaluate time and again in order to keep the metrics valid.

LWBS is one fine example of this problem. But it isn't the only one.

Other examples we have found seriously flawed are Length of Stay, both in Emergency Departments, Clinics and Inpatient Units; and First Case Starts and Block Utilization in Surgeries. In almost every case, the metrics painted a picture that was far better looking than the actual truth. And it was a painful process for the organization to understand and accept that truth.

While we have been disappointed in the initial numbers as they were revealed, we also saw profiles in courage: Senior hospital executives who realized what these false scores meant, and what the real scores were actually saying. Within moments for some, days for other execs, they each overcame their disappointment and anger and with grace thanked the managers who brought it to their attention. They moved swiftly on the news to clean things up and welcome any assistance from their managers, MDs and employees.

These Leaders have shown themselves to be leaders, because they were the first to overcome the natural disappointment when things turned out to be much worse than they thought. And they were willing to accept the consequences. Though those have, for some reason, always turned out to be very positive consequences. In our work it is common to see the C-suite executive receive a well-earned promotion at the end of the project when the poor scores were revealed, accepted, and then through tireless efforts of management at all levels, turned around into legitimate excellent performance.

So, the problem wasn't the leadership at all. It was fear. And out from behind the fear, with just a little dose of truth and coaching, courageous leaders emerged to the benefit of their hospitals and their communities.

Indeed, getting a more objective picture of the real metric was part and parcel of helping the organization make a rapid and sustained turn around.

In one hospital Emergency Length of Stay was reported to us at 6 hours, but in that Hospital it turned out to be 12 hours on average. But when we were done, it was 3.5 hours.

In another hospital, the metric showed 3 hours, but this turned out to be the LOS only for Discharged patients. When the patients admitted from the ED to the hospital were factored in, the over-all average LOS turned out to be over 5 hours. And this was reduced down to 3.3 hours overall, with a 15 percent increase in billable patient volume, handled with a commensurate improvement in productivity.

 Where did the 15 percent growth of Billable patients come from? Surely not their LWBS?

It didn't seem that way at first, but this bore out to be the true baseline:

How could LWBS be so far from the original reported metric?
Part of the auditing process includes direct observational studies in the waiting room of the Emergency Department. They aren't difficult to conduct, and they can be very revealing. Here, the department manager and their trusty Compirion consultant  spent a few hours during a busy waiting-room time of the day to see just what was happening:

(We thank David Northern, who designed this study, which has become a standard of practice in Emergency Department patient flow analysis)
















Here is a chart of the results. You can click on it to enlarge, then press the "previous" or "back" button on your browser to return to the blog.

On the left axis you have the time that the patient entered into the waiting room. You can see that the first patient to enter during the observation period did so at 5:45 PM. The last patient during the observation period to enter did so at 7:16 PM.

Along the bottom of the chart are the elapsed minutes of time for each patient's stay in the waiting area. Take the top bar. This patient came in and was seen immediately. The blue color represents some form of contact, care or service with a hospital employee. The patient came in and registered and had a quick Triage and this took about 17 minutes. Then the color turns to red. That is waiting time. The patient waited for an hour. And, upset at the wait, they left.

That LWBS was recorded because the patient had already registered.

A total of six patients were LWBS, but only two of these were recorded.

Take a look further down at the other patients. There are five additional patients who left after waiting a few minutes. Four were never registered or triaged. And they were never recorded as LWBS.

These four patients are indicated above with these descriptive labels :

PT LEFT / NO GREETER

PT LEFT / NO GREETER

PT LEFT / NO FASTRACK / CLINIC

 PT LEFT / NO FASTRACK / CLINIC

The first two patients didn't have contact with any hospital employee. But that isn't true for the last two patients. They did ask a registrar and a nurse  in the ED if there was a long wait, and if so, where was the clinic? Did they not have a fast track?


These patients had an expectation when they walked in the door - one which the hospital itself had fostered in the press when they proudly announced a few years earlier they had a "fast track", and when they aligned with a new urgent care center.

But the fast track had been discontinued. And, while a clinic did exist, it was closed after 6 PM.

Since these patients were never registered or triaged they were never included in the metric of LWBS. But they were there for a legitimate care need, and potential patients of the Hospital.

While two of these patients did communicate with hospital staff -  when asking about the fast track and the clinic - still, they were not recorded as LWBS.

There were staff in the Triage and waiting areas who had completed a lean patient flow improvement initiative a few months before Compirion was engaged to help take them to the "next level". Yet no hospital employee believed the LWBS metric to be anything but entirely accurate. And we heard repeatedly: They had just finished working on it a few months ago! And they were mystified that they couldn't get their patient sat scores higher when they had done such a beautiful job on LWBS.

It isn't simply a matter of observation, but observation with an open mind - open to the possibility that maybe things were not quite as the metrics told - even though so much effort and time had been expended on "fixing" the triage / waiting area before.

Sometimes folks can't see it unless their leader makes it OK to see it, and that sometimes takes just a little assistance.

ED PHONE HOME!

               

What’s the single easiest, fastest and most powerful way to ramp up your patient satisfaction scores by 30 percentile ranking points?

100% Patient Call – Backs.

Here is an example of what we are talking about from an Emergency Department we worked in not so long ago….

This was the result of a combination of changes. They started at 35 percentile ranking on Press-Ganey for the prior year. The target was 75 Percentile Ranking. As you can see here, within a matter of a month their scores shot up to the 98^th percentile ranking. Most consultants would pack up and plead victory at that point.

But as you can see, human behavior is not a linear process. And to sustain that behavior requires a host of additional changes and new behaviors: a transformed culture. It was after about seven months that we knew the client was going to sustain at least top quartile performance, at least 75^th percentile ranking. And with normal variation, they have held on average around the 79^th percentile ranking for the two years since the project.

Many changes were involved, including a house-wide throughput initiative which cut Length of Stay in the Emergency Department in half and got inpatients discharged from the nursing units by noon..

But today we’re going to talk about the one single most important initiative that made the biggest impact and that is 100% Patient Call Backs. We see time and again this is one very effective strategy, which can dispel hopelessness in the staff quickly and replace it with enthusiasm. Just don’t let it become complacency, because to sustain and further change, more needs to be done. But this is the best jump-start.

It may seem strange that something which has nothing to do with the patient’s experience during their visit to the Hospital could change satisfaction scores so completely.

WHY DOES THIS WORK???

There are several reasons.

I will present them in three basic comments; in the order of personal value, but not necessarily the order of actual statistical impact on scores:

1. A call-back to confirm treatment effectiveness and patient well-being is really the appropriate completion of care in the minds of patients.

In an excellent operation, whether it is in healthcare or any other business or service, the satisfaction of the client is confirmed live, person-to-person by a representative of the organization at the close of and again somewhat after the process is completed. It confirms that the client has received the entire service, and that the end point of that service is set by the client, not the provider. It is giving back the authority and control that every customer expects and is entitled to. They cannot enjoy what they have experienced if it is entirely not their choice. And in Emergency Care the options for treatment are largely out of the patient’s hands.

The Call Back is a way to restore that sense of control, that the on-going care of the patient is a partnership. It isn’t a matter of the patient being simply a mass of biochemical parts under the management of the MD when they are in the hospital, and then like a product off an assembly line, they are shipped out on their own without any further support.

In the Number One Hospital the whole person is involved all the way through, and especially after their visit. It is far more than another opportunity for service recovery and prevention of readmissions. It is the clinical opportunity to re-direct care and prevent problems from happening early when some part of the treatment needs to change.

Most ED visits, and hospital stays, end with some healing still to take place. The treatment actually is complete when the patient is healed, and that isn’t in the hospital. So following up until that happens continues that partnership, continues to give patients control over the problem, the trauma to which they were a victim, but now they are the one managing that issue, facilitating their healing and restoration in partnership with the Doctor, God and their family.

And their health crisis is an experience which can bring all a little closer together.  The Number One Hospital is very willing to share that experience, to participate in their appropriate role in that relationship since this is an important chapter, and can be a turning point for the better,  in the lives of their patients.

For this reason the follow up call should ideally be made by a clinician particularly versed in providing phone support and customer satisfaction. If that person can be the clinician who treated the patient, all the better. But if the patient’s caregiver is not particularly strong in managing the comfort and understanding of their patients, then it is best to utilize the help of an RN who does have great interpersonal strengths: listening and teaching skills. That is most important and impactful.

2. When patients leave, their experience is judged in retrospect, and that is a different conclusion than their experience while at the hospital. The two assessments are related, but they are by no means the same. How readily the patient heals, and how completely they heal influences their judgment about the Hospital. You can have very little influence on that at the time when they have not yet healed. It is after their healing is established that the Hospital can help the patient make a realistic assessment of that level of healing.

The call – back is a means of helping put that second opinion into a better perspective by offering to listen, to reflect, and to provide assistance to the patient once they are in that time period where they are making that retrospective evaluation.

3. Statistical Sampling. By encouraging all patients to complete the Satisfaction Survey during the after-care call-back, those patients who have made a generally good evaluation will be more motivated to reciprocate their thanks by making more effort to participate in the survey. Patients select whether to participate, and so the ones with significant dynamic tension, unresolved issues or complaints, will most certainly seek the ear of the survey. To balance the scales it is important to let all patients know that this survey is quite significant to the Hospital and it is something the patient can do to encourage the Hospital to keep up the good work.

When more patients who had a good experience participate in the survey, the over-all scores leap up.

NUMBER ONE HOSPITAL

Essays and Methods, Madness and Passion for Hospital Excellence

Hospitals are very complex, and they perform nothing less than miracles every day. Of all the organizations within a society, it is the hospital where the best in what we are as human beings, as a community proves itself.  Hospitals have always had a significant series of challenges. They struggle with reducing errors, improving service and satisfaction, raising the standard of health in the community while improving hospital performance. For a number of reasons, Hospitals are some of the most over-consulted and poorly led of businesses, and unfortunately, this has led many to avoid getting help when they need it.

Hospitals strive to run like businesses, but in truth the very best businesses strive in their highest ideals, in their wildest dreams to imitate what is found in every Hospital.

It is the Hospital which every minute of every day serves all humanity: the sick, the indigent, the downtrodden, the lost.  The Hospital's mission is a simple one -  life: To rescue, to save, to heal, to restore, to rebuild and set people on a better foundation for living; to trade illness, fear and threat of peril, anguish in the face of imminent threat of death, and replace these with hope, progress and life; and where that is not possible to help grow understanding, acceptance, and give comfort and peace.

In the journey to improve the quality, service, productivity and performance of Hospitals there is far more fad than fact out there about what actually works. And the issue of sustainability seems very illusive, though claims for it are common. The problem persists when people, be they consulting gurus or their "new program", or the hospital executives or employees, put themselves before the hospital.

Whenever you hear anyone say "Have you heard about the XYZ  Program! IT does great things!" run the other way.

Whenever you hear anyone say "Listen to this guy! He's a great Visionary!..." or" She's a brilliant Leader - follow her!" flee to the hills.

I started in patient flow and clinical performance improvement consulting in Emergency Departments in the mid - 1980s. The staff in my first Emergency Department were upset that it was taking 40 minutes for chest pain patients to go from Emergency Department front door to CCU bed. They wanted that time cut to 30 minutes, and they succeeded!

Today, any hospital that can accomplish as much in under 120 minutes is considered a top performer. And most take at least 180 minutes. Many take substantially more. And research verifies that the longer a patient stays in the ED, the higher their chance of infection, and the longer their overall length of stay as an inpatient in the Hospital.

In many of the most fundamental things, Hospital performance has declined.

So much for all the fads, scorecards, improvement projects;  the conversion to "for-profit" status; the implementation of DRGs; the reckless "remote control management" by insurance verifiers and better diagnostics. All these have made hospitals resource heavy at the top, often dangerously scarce at the bottom, and inefficient throughout.

And the great ideas that  lost their way in the packaging, profits and politics have come and gone, and come back again: Management by Objectives, Quality Circles, Statistical Process Control, Total Quality Management, Continuous Quality Improvement,  Reengineering, Six Sigma, Pillars of Excellence, Score Cards, Patient Centered Care, Mission Effectiveness, Vision-Setting, Patient Focused Care, Ideal Patient Experience, Lean Hospitals, Shared Governance, Revenue Cycle, Value Added, Meaningful Use, Rapid Cycle, Environment of Safety, Accountable Care Hospitals, etc..

How can all this work result in things that looked like improvement at the time, measured improvement, but which have decayed over-all quality of care over the decades?

Yet that is what has happened.

In 2011 the most innovative fad in Hospitals, enthusiastically embraced and praised as genius, is the use of a checklist and floor supervision (buzzword "rounding"). Entire national research projects have been mounted, procedures have been packaged and copyrighted, new Gurus have emerged in the great national movement to bring to Hospitals what was already there not so long ago: Things employees, head nurses, house supervisors knew about and practiced with vigor, but which have faded into obscurity.

These basic principles are not new notions, and touting them as genius, packaging them into a "program" simply draws attention from the dynamics that unraveled them, and indeed the "Program" is one of those dynamics.

Consider the Electronic Medical Record. Here is a great idea whose purpose was lost in the short-sighted financial gains of IT firms, Consultants and Hospital executives. In the rush to install electronic record and tracking systems, principally for the purpose of increasing patient charges and revenue, and secondarily to reduce errors, klunky systems have been put in place which require so much effort from nurses and physicians that their patients are neglected with all the negative correlates. The systems that existed before - paper checklists, supervision and inspection,  real-time communication, coordination and teamwork  - have been largely abandoned with nothing but weak shadows to replace them.

The paper systems engineered to support good care over many decades were tossed away. These systems could be held in your hand or put into your pocket and moved where the patient, physician, decision-maker, family were located, so that recording, management and care were seamlessly integrated. The EMR was supposed to take this much further by reducing the tedium of documentation and information transmission; providing great artificial intelligence to streamline good care, so that care-givers could spend more time, not less, with patients doing the right things better, more intelligently.

But now those systems overall take much more time than the paper. A physician often must go through ten different screens to make a single order, when once-upon-a-time they were able to make a 20 second request of the Unit Clerk.

With any given new patient or patient ready for discharge there may be a dozen such orders. This bottlenecks the whole flow of admission and discharge.  Hundreds of caregivers and techs must fight through a very inefficient process waiting hours to see the orders on the computer before they can begin. Once-upon-a-time, the MD spoke directly to the RN and the Unit Clerk at the same time for three minutes to get these things moving forward immediately.

Because the Gurus, Leaders and Tech geniuses promised this would streamline communication, people have stopped talking to one another and wait for the computer to tell them something is needed, something is ready. Their day is scheduled on the basis of NOT spending time in face-to-face teamwork with colleagues and patients. No longer making insightful physical assessments that were of equal clinical accuracy, now care-givers instead rely on batteries of diagnostic tests that are time consuming; which are completed long after the physician and caregiver have gone on to other things, and which clinically have not improved the Hospital's overall level of care.

And furthermore, because people self-select when and what to enter into the system, communication has broken down. The busy MD doesn't stop to enter the order into the computer until he or she has rounded with all their patients, hours later, batching work, piling up delay. The busy Housekeeper doesn't stop to enter the clean room into the system until they have cleaned all their rooms, causing patients to wait in the Emergency Department additional hours for an inpatient bed.

What was once a human system of teamwork and live accountability from one manager or care giver or MD to another, patient by patient, now has a non-verbal, non-live text based electronic intermediary that piles up batches before passing on the information. This has disrupted and destroyed much of the human accountability that once existed.

They have made it worse, not better. Is the Hospital able to charge patients more money? Yes. Is the electronic system reducing medical errors and improving care outcomes? No. In some cases, it is worse: A distraction causing delays, lost opportunities for care intervention, lost teamwork and communication.

Promises were broken, but that doesn't stop them from continuing to be made. Where is the acknowledgment "We did this wrong"? How can any real progress take place without that? How can any new promise hold credible hope?

Now these new systems aren't so new. They are five, eight and ten years old. But changing them has been very slow in coming.The bigger systems that talk to each other are still klunky. The tiny systems that have some utility for clinical management don't communicate well with any other centralized billing or record systems, so duplicate entry is still necessary.

It is nothing but business competition among IT firms which has created this lack of coordinated effort and fragmentation in the tragic story of the EMR.

So much time has elapsed in this story that the tools and practices of great care from the past have been lost, rather than transformed through technology and teamwork into something greater. When past Hospital executives, nuns, nurses, managers, technicians and physicians retired vital lessons were lost. No one was interested in learning to do what they thought they would no longer need to do.

Improvements in one area can be real and significant, but when they are over-sold, people are led to believe they don't need to do common sense things anymore, like walking around and inspecting work, or checking in with patients or colleagues, or double-checking a verbal request, or confirming that request was filled.

When one small thing is fixed, what is the cost to other important practices that affect patient care, safety and satisfaction?

By making the old entirely "wrong" in order to grow a career on the new, the seeds of self-destruction are planted by the very process of implementation. So then you have replaced the old with a system that doesn't actually accomplish what was being done before, and is also doomed for the scrap-heap.

This is why Hospitals are the dinosaur graveyard of information systems, and "improvement programs",  purchased and out of date by the time they are implemented. Or worse, harmful to patient flow and care.

In this way such "improvement projects", enthusiastic for a moment, create lasting distrust.

It all looks great, but like an addiction, harms the host.

There is a myth perpetuated by those who have built their careers in just this kind of short-term exploitation. It is the myth that says a great leader comes in for a short period of time, dismantles what doesn't appear to work, makes major change, and goes away, leveraging the credit they have taken for themselves into their next higher-paying job.

But what really happens is that the most critical source of support for sustained change, the leader, is now gone.

Now that "leader" learns nothing about what it really takes to sustain change. They learn far less than those who must live with change for an extended period. You have leaders who know dangerously little about sustained quality care, fixing a small problem by dismantling an entire system, leaving it in pieces.

And the next leader makes their mark by making wrong the previous leader's "accomplishment".

In contrast,  Hospitals that really do perform well over a sustained period of time have a stable leadership.

Great leaders are people you may never hear about, because they are professionals at putting other people onto the awards platform, other people's names on the publication, other's faces in the news photos: and their organizations quietly get better and better year after year.

Since they aren't searching for their next promotion, getting credit is personally useless, but giving credit is a critical strategy for sustainability.

So the good news is that there really are great approaches to doing remarkable things and some very fine Hospital executives who practice them.

But to find those methods, to adopt those, you need to be right with your own beliefs, and then versed in these approaches, at least in concept.

If you don't really love to watch great care being given, and to work long hours to help others to do better, find work in some other field, not hospital leadership nor hospital consulting.

This Blog is for those who really enjoy seeing a great patient / caregiver interaction. Those who, when they see it, feel more enthusiasm than if their favorite team won the Superbowl. Because their true "favorite team" is the team working at the Hospital. Executives and Consultants who would rather come into the Hospital on weekends to walk around and watch what's going on, and meet with the team, lunch with the team, watch the team in action,  than to sit in box seats at the world-series or court-side at an NBA championship. People who feel, not just think, that the greatest performances in the world are those of Hospital staff and MDs, and who also bring their kids in to see the miraculous works taking place. Executives who feel more pride, more elation when they see a nurse, a tech or a doctor help bring peace and resolution to a family in crisis in their hospital, than if they were surfing in Hawaii, scuba diving in South America,  skiing in Colorado or geocaching in Turkey.

And when such leaders and consultants don't feel so great, they go out and watch a tech deliver needed supplies on time; a pharmacist give a great consult to a physician; a rehab therapist carefully, lovingly ambulate a patient. This is their restoration of well-being and purpose.

This blog will serve as a public forum for a variety of methods developed and implemented in Hospital Leadership, Organizational Development, Clinical Care, Operations Improvement and Business Management over several decades. Strategies that have cut mortality rates by 30% or more; erased infection rates; that have raised patient satisfaction rankings into the top 1 percent and even to the very top position across several states; that have eliminated unnecessary readmissions; that have cut throughput by 30-70%, eradicated Left Without Being Seen,  improved productivity by up to 30% while cutting hospital costs by an equal amount; and this done without a single lay-off,  while ramping up staff and physician satisfaction to their highest levels in the history of the Hospital.

We invite everyone to share what they have learned in the spirit of service to our community.

Compirion Hospital Solutions holds no copyright on any of its materials or tools, and gives these without reservation to both our clients and anyone who asks. We only reserve the right to use such tools and methods in our future work without royalty. Our clients can and have repackaged what we have done, and that is their privilege. They do so with full ownership and authorship, and with our complete blessings.

But we believe Hospitals are a public trust, and the costs of ignorance far too great: The public is the rightful owner of whatever is developed.

We believe Hospitals belong to everyone regardless of where they call home, regardless of race, creed, religion, lifestyle, color, sex, citizenship, age or ability to pay. If they need care, the closest Hospital belongs to them. It matters not that the Hospital is "for profit" or "not for profit" because it can only be run well over a long-term period as the servant of the People. We believe the Hospital is a gift to its leadership, MDs and employees, as well as its community: And a privilege, an honor to associate with. When working there is understood to be a sacred gift, a calling that is given to each person who works there, and which must be honored with thanks, and cannot ever be adequately earned, work improves.

Hospitals belong to their purpose and no one else can claim ownership. You can pay people to work in a place. You can heal systems that are damaged. But the fact that you  also get the whole heart, body and soul of every patient, employee, MD and manager which are priceless, under your direction, and you accept these resources and the duty to lead them, means that the debt on the part of the "owner", the "executive" and the "consultant" to the employees and the community grows ever larger with each passing day.

The caregiver and the patient grow richer by far. The growing debts of the owner, leader and consultant soar by whatever they take as compensation - both tangible and intangible - which is not immediately reinvested into the operation of that Hospital.

So their only hope to help balance the scale is to assist in whatever way they can the caregiver, the patient and the community. And to beg for strength and wisdom to do so effectively; and discretion to do so without harm.

We have shown hospitals how to become more profitable by far adopting this belief; committing to it, regardless of the challenges, and working together with the whole organization to build the right answers, and avoid cutting corners for short term personal gain.

Hospitals can eliminate most all medical errors, eliminate waste, inefficiency, poor morale and  raise their satisfaction levels and their financial margins to new heights. It has already been done several times.

And while making good use of natural resources, creating value for society, and being productive are great values of stewardship anywhere in this world, they are certainly most important with human resources when human life is at stake.

We hope that the tools, case studies, methods, analysis and advice offered here inspire others to share as well, and all to reap the benefits with the objective of providing the best healing experience possible to the entire community.

Spence Tepper