Suboptimizing an Australian ER

‘Surgery should be halted’ to clear hospital backlog

Sub-optimizing decisions are a fairly universal human behavior, regardless of the industry (or continent). Lean teaches us to look at “value streams” that go across departments and to view operations from a “systems” standpoint, looking at the complexity and the interconnections the best we can.

In the article I’ve linked to, an Australian hospital has a pretty common problem — the ER is full because they’re having trouble getting patients into rooms, the so-called “boarding” problem where patients are kept in the ER longer than they have to. It’s a systemic patient flow problem that goes across departments. It might be an overall hospital capacity issue, it’s sometimes a process issue where the discharge process is inefficient and inpatients are kept in rooms longer than necessary, thus backing up the ER.

When the ER is full, the hospital can’t accept more ambulances. It sounds like, in this case, the patients are kept waiting in the ambulances, which is bad for the patient and it ties up the ambulance resources.

“A specialist in emergency medicine says hospitals in south-east Queensland should stop elective surgery for up to a month to clear a backlog of emergency cases.”

Think about that for a minute. To solve the ER problem, you’re going to STOP doing elective surgeries? That seems like a “solution” that a specialist would come up with — concerned only with their own department, the ER, apparently.

What are they going to do to solve the elective surgery queue that would grow by one month??

We need systemic solutions to problems like these. Easier said than done, but Lean methods are having a huge impact with hospitals around the world.

Here’s a longer article on the same story. Here, it claims the doctor is asking for a “two day” stoppage on elective procedures. That’s better than a full month, but still isn’t getting to the root cause of the patient flow problems.

Dr Knox said although stopping elective surgery was not a long-term fix, the situation needed a circuit-breaker.

“If you stopped elective surgery for two or three days, you could then clear emergency departments and let them recover,” he said. “I think that’s the only immediate solution.”

At least he realizes it isn’t a long-term fix. The queue would eventually re-form if the flow isnt’ balanced.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

6 Comments on "Suboptimizing an Australian ER"

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  1. Anonymous says:

    Isn’t that what the corporate world and business schools are teaching managers. I have MY budget and will focus on MY objectives.

  2. Mark Graban says:

    Unfortunately, yes. I’m not saying hospitals are any worse than other industries.

  3. curiouscat says:

    I may not have thought this through but couldn’t adjusting elective surgeries serve to balance the flow? Granted I know next to nothing about the gemba of a hospital so what do I know (and it is a fairly lame way to balance the flow).

    And I don’t know how obvious the building pattern to overflow is (like it would be wonderful if it slowly went up over the course of a week getting further and further behind. then you could intercede as you saw it start to get bad and slow down scheduling elective surgery for the while to give it some time to catch up. Somehow I doubt the real system would work that way :-(

    I would imagine a system that had capacity to work on emergency care when needed there and could shift to other work as available would be ideal. But My in depth knowledge from watching ER doesn’t lead me to think this would actually be done in practice. Sortof like this Toyota Service Dealer example. I would think from a customer service perspective emergency room emergencies would take priority. But my pop hospital administration knowledge tells me that isn’t where the money is (and doctors would rather not deal with inconvenient emergencies) so both might not like a system optimized to deal with emergencies first and fit the other stuff around that need.

  4. andrewmc says:

    This is a real problem in all hospital systems. The UK in one sense cracked it by putting in place a target that said no patient can ever wait longer than 4 hours from arriving at the ER to being discharged or admitted. Now SOME organisations gamed the system and created short stay observation wards and so on and so forth but most changed the way they work to meet the target.

    The problem is that the variation in A&E emergency admissions is to varied to use elective to fill around it. In order to do this you’d have to tell some or all of the elective patients that they are in a line and will be seen in chronological order and you think you should get to them based on historical demand the 3rd week in September but it could be sooner or later depending on those admitted as emergencies in the mean time.

    It is incredibly difficult to balance emergency and elective surgical flows. One thing that can be done though is to change the way patients are triaged and the conditions that they are admitted for. For example some patients suffering a trauma type injury of the leg and foot might require surgery but prior to surgery they may need some time to become stabilised. Depending on the injury it might be possible for these patients to go home for 24-48 hours and then be re-admitted for their surgery where as traditionally these patients have been provided with beds.

    This is an incredibly difficult problem to solve, if you prioritise the emergencies all the time patients waiting for elective surgery will be penalised and if you keep them seperate and its a quiet day for emergencies slots go to waste.

  5. Mark Graban says:

    To curiouscat — you’re right, there IS a need (and opportunity) to level load elective surgeries throughout the day and throughout the week.

    I don’t have the data in front of me, but I’ve heard enough hospitals report this to think it’s generally true – the pattern of elective surgeries is LESS level than the pattern of surgeries that come via the ER. The ER usage is normally very predictable, you can anticipate when the OR’s will be needed by the ER patients (other than in cases of extreme catastrophe).

    But, the “need” to stop elective surgical procedures for two days or a whole month would seem to indicate a wholesale capacity shortage that needs addressed.

    Some questions to ask:

    1) What is the utilization of OR’s throughout the day? Are they underutilized in the afternoons because everyone wants to do surgeries in the morning?

    2) Are you blocking out times for particular surgeons, who then don’t use the time, letting the room go to waste?

    3) What are your standard methods (and times) for room turnover between procedures? You can often free up capacity through this and other operational improvements outside of the surgery itself.

    It just seems irresponsible to just stop doing procedures, even if “elective.”

  6. andrewmc says:

    The pattern of elective surgeries is less level for a variety of reasons, not because the demand is not constant but because of Mura.

    The uneveness in elective surgeries is simply because of the way that primary care and secondary care choose to manage them. For example a orthopod may run his out patient surgeries on Tuesdays and Thursdays and only operate on Monday and Friday mornings.

    If the orthopods do not pool referrals depending on the day you are referred you could wait anywhere between a minimum of 24 hours and a maximum of 5 days.

    Time is almsot certainly carved out by Trauma and elective and then by each surgeon working in a specialty so its very possible that you could have some sessions under or not utilised at all. For example 3 weekends ago a hospital that I was working in admitted nearly 30 people in 48 hours for trauma sugery up from 5-8 per day.

    This just causes chaos. Thankfully the rest of the week fewer patients were admitted but lets say you have no trauma was admitted, how can you get people in for elective surgery at no notice. Most people when confronted with an elective operation have to plan around it, so they are give a date and a time and show up and expect it to be carried out. If on the other hand a hospital expects 5 trauma surgeries to be performed per day and none are admitted it is very difficult to fill those slots at no notice.

    As to change over, there is unquestionably room to improve the question is whether on a 10 hour all day list completing 4 knee’s or hip’s, saving 15 minutes on the change over is of a material benefit.

    I was in a 2.5 hour knee replacement last Thursday afternoon and I am not sure that I’d have wanted to be the next person on the list or to try and get a 5th joint instead of the current 4. It is physically exhausting work and to stand for 10 hours and conduct surgery has to be draining.

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