Monday, April 10, 2023

This Dinosaur Must Die

Hospital care and diagnostic work is still, classically, woefully, wasteful and inefficient

One of the most prevalent and greatest sources of inefficiency in hospitals is the unsynchronized and unmanaged execution of various care and diagnostic activities. It's gone on for so long it's become invisible to care givers, managers and executives. 

The persistent inefficiency glaring to any hospital patient and their family members, has become non-existent to the very people who must work to fix it. But there it is. 

Less than half of a hospital caregiver's time is spent with patients...and there are 4 other employees, who don't work directly with  patients, "supporting" them.

It is common to see less than half of a therapist, lab scientist,  technologist, nurse and physician's time with their patients during peak day hours, and that is often their highest percentage of direct patient care time throughout their day. 

Elvis Has Left The Building

The effect is substantial delay for patients and a demand for large numbers of highly trained professionals who, today,  are just not there. And who will manage these crew? Experienced management have left the building. 

The result, growing gaps in care

Despite a large constituency of Performance Improvement departments, executives and consultants who have worked on efficiency year in and year out, little lasting or real improvement has been made. Or, more precisely, improvements that often are incredible and have substantial impact on bottom line, quality and morale are allowed to fall apart without leadership commitment to conjoint professional accountabilities: Leadership to continue the effort, because, indeed, sustained higher performance is a sustained effort. 

With good leadership, the effort is a point of pride. Without leadership, the ones still making the effort are targeted for ridicule.

Humpty Dumpty is just a broken shell of his former self 

Once these painstakingly built and implemented solutions fall apart, it is a monumental task to rebuild them: The task facing Hospital management and executive leadership today. 

Most Care and Diagnostic Work is compressed into one-third of the available time

Roughly 75% of all patient care and diagnostic work is ordered between the hours of 6 am and 2 pm on weekdays. That's 75% of the work ordered during only 24% of the total hours every week. Or only 36% of the total patient waking hours during the week. 

That's compressing 75% of the Diagnostic and Care work into  one-third of the available patient care hours.  It is done so everyone can work something like a "normal" schedule: come in at a reasonable time and leave on time. However, without solid work synchronization,  adding work compression on top of clinical order batching leads to derailed care:  Patient admissions, transfers and discharges are all held up, each passed off to the next shift, doubling or tripling handoff work, delay and risk.

Work compression, work batching,  unsynchronized and uncoordinated activity, error, waste, rework, delay and rescheduling have plagued hospitals for all the decades of hospital history. 

The Dinosaur practices still roam the earth, though now they have EMR road signals and saddles. But they are still Dinosaurs. 


There was a day when highly skilled people managed patient care with complex subtlety as one

The lost arts of collaboration in real time are known in places.  The superpowers of nearly telepathic teamwork and a much broader range of professional  responsiveness. These required highly trained, situationally aware and skilled individuals who connect immediately to their patients and each other. 

While the new Dinosaur practices have multiplied, with the help of technology,  to replace the old, the newer crew in settings without good veteran supervisors and mentors, know nothing of that.  They go forth unaware, assured that following the orders of their AI-generated worklist represents the bulk of their professional duty and assume this to be best practice. It is all they know. 

Are there alternatives? Yes, and they have been implemented here and there successfully in some of the nations' best hospitals years ago. They produce better margins and stable crew over time. But they are long-term investments in crew deeply imbedded into the very fabric and history of the hospital.

Linear Flow EMR Work Lists are new silos, Baby Dinosaurs


Technology has helped inform, but hurt patient flow.

Now new physicians in the ER insist on seeing test results first before they see their patient. And in many cases never see their patient. They have replaced eyes-on-patient-first with eyes-on-computer-first and sometimes only.

Instead of working in real time, transparently, with their team, now work is stacked in the EMR in lists. 

Managing the list leads to batching, which is very efficient for the one managing their own list, but terrible for care across multiple work lists. 

The EMR thinks your groceries are the meal and so it took away the kitchen

The EMR work list is a seductive temptress: Maybe you don't need as much collaboration or conjoint accountability or real-time participation in decisions anymore?  Maybe you don't need supervisors anymore? The worklist is the hero to an environment where everyone is asking for different, at times conflicting things.  Let's just spend our time in our worklist.  Let's let our worklist tell us what to do. 

People value what they attend to, and by requiring so much attention, behaviorally, the worklist becomes the boss.  

The best-practice process  of diagnostic and care planning and execution is quite different. It uses the EMR, as it uses every available human and technological resource to its best capacity. But it's not elementary school math. It isn't linear one-dimensional work lists. Best practice care is real-time, multi-dimensional, multi-disciplinary, multi-factorial.

 Best practice diagnostic and patient care is medical science, care management, neuroscience, group dynamics, social science, psychology and multivariate analysis in real-time. It isn't data then decision. Sometimes it's impression, sharing, exploration, hypotheses, dialogue, learning through action that alters team understanding and subsequent action.  

Before they met the team they thought they knew some of the data. Together, in discussion with their patient and each other they grow knowledge. While they are together and while they test, examine and care for their patients,  ideas arise organically and flow with new results seen or reported, into becoming new information, agreement and coordinated action. This solution is largely collaborative, participative, and creates lateral accountability and the highest level of vigilance and inspection in real time. 

The old Dinosaur practices are wearing new software clothing... But...

This Dinosaur Must Die

And perhaps now, in the post-Covid economic and human capital environment, it may.

But it won't go down without some effort, and true people-building, team-building, profession-honoring, clinical and quality work engineering.

No comments:

Post a Comment