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.
No comments:
Post a Comment