By October 22, 2007 9 Comments Read More →

A Very Non-Lean ER Experience

Thanks to a Lean Blog reader, Matt, for sending this first-hand account. I’m sorry he (and his wife) had to go through this experience. This is posted with his permission. I’ll buck convention a bit and put my comments in the quote boxes. Matt’s text will appear as the normal font below.

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Saturday night I had to take my wife to one of the local ERs. We got there at 9:40pm. When we got there, I filled out paperwork to register her with all the basic information (name, symptoms, SSN, address, etc…….). Then we had to sit there and wait……..and wait…….and wait. This was especially frustrating since my wife was curled up in the fetal position in extreme agony and no evened seemed to care.

Mark: This is sadly reminiscent of this episode at an LA hospital, but Matt’s wife survived the E.R. encounter, in this case thankfully.

The maddening part was there was no privacy (except chest pain). Everyone else in the ER had minor things (sprained ankle, minor headache, etc……..). After we checked in a mother with a baby that could not have been older than 1 came in. The baby was green! It freaked me out. It was the one person I thought should get bumped in front of us, but they didn’t. They waited in the FIFO line too.

After 3+ minutes we got called into the triage room where about half the questions got asked again that were on the sheet I filled out. I found this frustrating since the data from our registration sheet was put into the computer and that is how triage got our name and called us in. Where did the rest of our data go? Why ask again? The triage nurse said this was part of registration.

Mark: This is a very common waste seen in E.R.’s — definitely the waste of overprocessing, or a defect in the process that you have to repeat yourself. There’s a minimal amount of repeating that’s necessary to confirm they are looking at the right patient, but I’m sure some of the information just didn’t get passed along. That’s something many E.R.’s that work with Lean fix, only asking for information once, instead of multiple times. It saves employee time and causes less frustration for the patients. The nurse obviously doesn’t feel too empowered to “kaizen” her system… just doing her job…. what can you do about it? That’s a sad attitude to see, the culture creates that mood.

Then we went back out into the waiting room and waited for another hour before they called us back. As they were taking us back they stopped me and said that I had to register to go back with my wife. I had to register at the same desk as the first registration an hour and a half earlier. So, my wife is in agony and can barely walk and I have to stay up front and to have my ID scanned and a sticker badge given to me. Then I get let in and I have to search for her room. I finally find her and we wait for a third person to come in and ask the same registration questions again. She is even wearing a badge that says “Registration” on it. My wife asks why this wasn’t done in the waiting room where we have been for that last 1.5 – 2.0 hrs. The lady replies that “this is just the process.” We could’ve had all the registering done in the waiting room up front. This seems to be a little more batch (“batching all the paperwork up front”), but I would argue two points: 1. there isn’t as much batching as one might think because we are getting all the same questions over and over with a couple of new ones, and 2. this would be more customer focused because my wife is in pain and we wouldn’t be separated plus she wouldn’t be getting upset about answering all the same questions over and over again. At this point, my wife looks up an me and says, “This isn’t very lean is it?” I was glad to see her smile through the pain.

Mark: Matt and his wife made the point perfectly, so I won’t elaborate much. Matt should have been able to register while they were waiting. Again, there’s more of that “well, this is just the way it is” attitude from the staff. That’s something you would have to work on during a Lean implementation, convincing people that they actually can work at improving the system, not just accepting it for what it is.

We wait for a long time and finally see a doctor who orders a CT scan, so we wait for the scanner to be setup and then we wait for the results and then we wait for the doctor, etc…………..

During all this waiting I speak with some of the nurses. At this point it is about 1 or 1:30am. The nurse tells me that this is a real slow night. Usually the halls are lined up with patients. I notice that they can’t find their electronic thermometer and go borrow one from another area, the supply area is labeled but is very messy and can’t tell how much is suppose to be there. The nurses can’t find things and quite a few times are just sitting around talking about their lives outside of work. They spent a lot of time doing this. Not because they don’t care but because they are waiting on doctors and information and whatever they need to treat the patients.

Mark: So there are 5S and organization issues… people can’t find things, that leads to wasted motion and waiting time. Again, very common. The idea of people just sitting around and talking about their lives…. sure the nurses might have waiting time (waiting on others), but you can also see the opportunities to use that time for kaizen. Or, if you reduce waiting time and improve the flow of work, the nurses are going to lose some of that watercooler time. Then, will they perceive they are “working harder” or will they be happy that they can spend more time on direct patient care (the “Value adding” work)?

The most disheartening thing I heard all night was about a computer. I heard that they had test results back on the baby that was green (and I literally mean green) but nobody has been able to view them for an hour. They were having problems getting the computer to work so they called IT. There was no manual override or way to get results so the baby couldn’t be treated until they got the computer working. WHAT!!!!!!!!!?????????? I couldn’t believe what I was hearing. I don’t know what happened to the baby and the test results but I hope everything turned out alright.

Mark: There definitely should be a backup plan or a manual process for getting that result. Worse case, they should have been able to go to another PC, unless their whole information system was down. Even then, they should have been able to make a phone call to the lab to get those results. I wonder if people didn’t know the backup process or if they were too busy to take those extra steps.

At 2:30am, we finally left the ER with pain medicine in hand nearly 5 hrs after walking in the door. I figure only about an hour was value added. This house is being generous too because it includes the walk time to the CT scan and the 20 minutes we had to wait after receiving the pain meds before we could leave.

Like you have said, the doctors and nurses were great people and wanted to help. The systems just sucked!!! I was thinking about lean stuff all night and trying not to blame the people but at times I would even find myself getting upset with the people “just sitting there” and not helping. My emotions would just take over as I watched my wife in pain.

I have always believed that lean is for everyone and every place because it is the mindset. Saturday night was just one of those “hit home” experiences that brought it to light.

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Matt, thanks so much for sharing that experience. That scene is repeated many times over every night. This shows how difficult it can be to NOT blame the individuals working in the system. Sitting around and chatting about home or Dancing with the Stars is just a symptom of systemic problems. It takes leadership to solve situations like that, and Lean can help. The good news is that Lean IS helping, we just need more of it, at hospitals like the one Matt and his wife went to.

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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.

9 Comments on "A Very Non-Lean ER Experience"

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  1. Anonymous says:

    It seems that Matt’s wife was a true emergency.

    What do you think about solutions like this?

    This sounds like setting up two separate “value streams” right? Push the non-emergencies to a different value stream so they can focus on true emergencies? Is this “Lean?” Many hospitals are doing this, it seems.

  2. andrewmc says:

    For nearly 10 years the UK has had two streams of work in the ER. The first is majors and the second is see and treat.

    This is now being taken a lot further. Upon registration in the ER you will be either “Meeted and Greeted away” to a more suitable provider such as your primary care physician or a PCP who works in the ER. Alternatively if you stay in the ER you will go down one of two paths; the first is see and treat which is run by Emergency Nurse Practioners who can deal with minor injuries such as upper and lower limb issues, stitches and other minor ailments and during this visit you will not be seen by any MD, the second pathway is majors where you would be triaged and seen by a MD and then referred on to a specialist.

    The target in the UK is that 98.5% of attendees in the ER are discharged or admitted within 4 hours and virtually all trusts in the UK comply and whilst their are occasional breaches which comtribute to the 1.5% failure these are incredibly difficult / impossible to mitigate without having enormous numbers of staff sitting idle simply to cope with unanticipated surges which occur less than 1.5% of the time.

    The next development of this is currentlt being implemented in a number of trusts and it is called a Urgent Care Centre where the minors, primary care issues and non-major attendences are being kept completely out of Hospital and are being dealt with by the ENP’s and MD’s in a seperate organisation.

    In parallel those that are attending the ER appropriately are being assessed and if they are deemed to be short stay (less than 72 hours) medical or surgical patients these are being put in to specialist short stay wards managed by the ER department with attending surgeons and clinicians and they never get in to the general hospital population. These prevents them from staying longer than necessary and maintains separate flows based on length of stay. The short stay patients becoming effectively runners, whilst the longer stay in the main hospital are the repeaters and strangers.

    This has been so successful that we (the NHS) are assisting one of the US teaching hospitals to put in place the same system.

  3. Mike Gardner says:

    1. Our local hospital has an ER and a non-ER clinic system like those described above and it works well to weed out the non-emergencies.
    2. We have had to visit our local ER a few times in the last couple of years and never had an experience even remotely as bad as described in the post, thankfully.
    3. Mark, I understand your take on the system being the problem and you obviously agree with Dr. Deming’s assertion that the people are victims of the system they are forced to work within. You also mention it takes leadership to fix this situation. All true, but one of the most critical things for any real transformation is for the workers to stop believing they are victims of “the system,” get up on their hind legs and start fixing their own situation. Informal leadership is as important as formal leadership. Sorry, but I DO blame these hospital employees for their poor performance. They can do better, they only have to WANT to.

  4. Neutron Jerk says:

    Let me chime in… individuals DO have a role to play in improvement. But leadership has to kick start that process.

    Otherwise, you have the dynamic of:

    1) Employee says “I have an idea, we could…”
    2) Manager says “No that’s a dumb idea, get back to work…”
    3) Employee says “OK, I’ll talk about Greys Anatomy instead of trying to help.”

    It’s not that people are VICTIMS, but one isolated “worker” usually has a very uphill battle to “just fix things” unless they are a pretty amazing individual. Leadership has to lead and help set the tone for improvement to happen.

    So I guess you think Deming was full of crap, then? Based on what? Care to name a time YOU got up on your hind legs and miraculously fixed a bad system you were a “victim” of Mike? Please, let us learn from your superhero like ability to fix a bad system.

  5. andrewmc says:

    I work with arguably one of the best hospitals in the world who have certainly if not the best one of the best ER’s in the UK and the leadership there is phenomonal. The fact that the person that leads happens to be a clinician is secondary to the fact that she has led and implemented changes in emergency care that are simply world class.

    From skilling up ENP’s to assume more senior roles, to implementing short stay wards, and the development of standard protocols for a huge number of conditions that can be printed by junior MD’s and others to ensure that the treatment that each patient receives is consistent patient to patient.

  6. Mark Graban says:

    In reference to Mike and Neutron’s comments… I don’t think blaming workers is productive. They are part of the system and I agree that’s different than being a “victim.”

    We could go through a “5 Why’s” exercise. Why are they sitting and just flapping their gums instead of improving the system?

    That would all be speculation, but it’s probably not from a root cause of “not caring.”

    I’m not making excuses for people, but be realistic… in your workplace, why don’t people drive improvements?

    1) They’re tired or mentally exhausted (bad system design)

    2) They’ve tried before, with bad results or bad response from management (bad leadership)

  7. Mike T says:

    All:

    Seems like a “Chicken or the Egg” situation. Without good leaders, change is nearly impossible. However, without people willing to stand up, change is nearly impossible.

    Have I always had good leaders as someone who truly believes in Lean for US company success? No. I’ve often been “at odds” with those above and around me. I could have given up on Lean as a concept years ago. I could have been like everyone else and decided to simply talk about last night’s football game, rather than look at ways to improve my situation (anyone know who won last night?). From that perspective, I (even as a ‘lowly’ employee) have made a decision not to be a victim.

    Now, in the Chicken/Egg theme…has management made it extremely difficult to institute change? Absolutely. Every day I deal with people who only want to complain about how they had ideas in the past and management squished them like bugs. How many times can a person’s ego handle being beaten down. The system has corrupted so many that the few who remain untainted have an uphill battle. The system needs to change.

    For certain, one of Mike’s statements is right on track, INFORMAL leadership is as important (IF NOT MORE IMPORTANT) than formal leadership. Both are needed to succeed – certainly in a Union environment, where I am today.

  8. Mike Gardner says:

    Sorry, but I do not respond to accusations and comments made in the manner Neutron Jerk has done. I’m not out to prove anything, just expressing my opinion, which is worth exactly what each person takes it as being worth.

  9. Bob Graban says:

    Sorry to hear about Matt’s experience.

    Like most processes, there are also some very good emergency rooms as well as some very bad ones.

    About a year ago, I had the experience of taking my mother-in-law to the emergency room at St. John Health Systems in Detroit when she was experiencing trouble breathing and chest pains. When we got there, they took her directly into a treatment room and started treatment, even though it was not what I would call critical. I kept waiting for all the paperwork, but I was told that since she was already in their computer from some tests she had earlier (elsewhere in their system), it was not necessary to go through all the paperwork again. I don’t believe they even asked for the social security number, much less her insurance coverage.

    The hospitals in Detroit are seemingly competitive in their emergency room care. Detroit Medical Center has a guarantee that you will see an ER doctor in 29 minute or less – I don’t know what happens if you don’t.

    By the way, I noticed that St. John Health systems is looking for an administrative director of their emergency room services if any blog readers are interested and feel qualified to apply.

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