How NOT to Improve Patient Flow: Laws, Targets, Blame, and Threats

Before getting into today’s post… I hope you’ll join me in donating to the Red Cross hurricane / flood relief efforts for the people of Texas who are affected. I’m fortunate that the Dallas / Fort Worth area is far enough inland that my family and I were not affected. Please give if you can.


Let’s start by stating the obvious: it sucks to wait 24 hours or more on a stretcher in an emergency department hallway waiting for a real hospital bed.

I think there’s agreement that waiting 24 hours, 12 hours, or four hours for a bed after an admission is a problem. That’s a problem worth working on.


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It’s a problem in Montreal, as the Montreal Gazette reports:

ER overcrowding remains a problem in many of the city’s hospitals, including at the Royal Victoria, Jewish General, Maisonneuve-Rosemont and Notre Dame. At the Royal Vic at the Glen site on Wednesday morning, the ER capacity soared to 130 per cent. Of that number, nine patients were receiving care in the ER for more than 24 hours.

At the Jewish General, by comparison, the ER capacity was at 102 per cent, and there were no patients languishing for more than 24 hours.”

It’s sad and frustrating to have a couple of blog readers from Canada send me this story from Quebec:

Quebec wants 24-hour cap for patients waiting on stretchers in ERs

Barrette says there would be consequences for hospital staff, doctors who don’t comply

Here’s one of the tweets directed at me about this:

The province’s Health Minister, Gaétan Barrette, wants improvement… so that’s good.

“In a bid to fix overcrowding in emergency rooms, Quebec Health Minister Gaétan Barrette wants to limit patient waiting times on stretchers…”

Overcrowding is bad. Long waits are bad. Fixing these problems requires a systems view… looking at capacity through the entire healthcare “value stream.”

But things start falling apart toward the end of the first sentence about this:

“…and give hospital administrators the power to discipline doctors and staff that don’t follow suit.”

The unfortunate implication from the Health Minister is that “doctors and staff” are the problem, or that “doctors and staff” aren’t doing enough to help. That seems very unlikely.

The Health Minister, who has been in politics for a while, is (or was) a physician, so you’d think he would know better than to blame doctors for systemic problems.

Gaétan Barrette graduated in medicine from the Université de Montréal and is an associate member of the Royal College of Physicians and Surgeons of Canada. He engaged in postdoctoral studies in vascular and interventional radiology at the University of California, San Diego.”

I did some work with a hospital in Ontario a few years back that had similar challenges. In a week with them, we discovered systemic problems, including:

  • Lack of budget to fully staff all of the newly built (and ready to use) hospital beds
  • Lack of space in the community for nursing home and extended care facilities (also driven by budget constraints)

None of this was the fault of doctors, staff, or hospital administrators. They all cared. They all wanted to make things better… but they could only do so much within the constraints given to them. Lean wasn’t going to be any sort of easy, quick, magical fix (and they were somewhat disappointed to hear that). You can improve the inpatient discharge process and communication flow all you want, but if there’s no place to discharge the patient to, well then you’re stuck.

Back to Quebec, where Barrette wants to make changes to a law that would:

“…cap, at 24 hours, the maximum time patients are forced to wait on stretchers in ERs before they are released or transferred elsewhere.”

That’s easier said than done. Setting a target that’s not achievable leads to people gaming the system and fudging the numbers, whether that’s workers at Wells Fargo or people in the British NHS hospitals, who had their own four-hour emergency waiting time targets.

Gaming the System: E.R. Targets

The Minister not only blames staff, but threatens punishment and pits healthcare professionals against managers (when they should be working together):

“The amendment also includes potential disciplinary actions against hospital staff who don’t follow the 24-hour rule.

“So doctors are sent the message ‘Look, if you don’t cooperate, there could be consequences’ in terms of disciplinary actions for instance,” said Barrette.

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He added a message to hospital administrators: “Now you have the leverage.”

The implication is that administrators haven’t had “leverage” over doctors and staff.

Maybe Barnette should be asking “why?” instead of lobbing solutions at hospitals.

The average waiting time in 2017 is 13.6 hours, but not not every waiting time is average. The average waiting time is lower than 2016, but:

“there are still too many patients spending a day or more on stretchers in the ER.”

I agree with the pushback on these threats of punishment:

“Chantal Marchand, the president of the association that represents health and social service centre managers, said the threat of disciplinary action against her members will only contribute to a climate of fear.

I agree with this tweet:

A patients-rights advocate has it right in saying:

“Paul Brunet, of the Conseil pour la protection des malades, argued that Barrette is tackling the ER crisis the wrong way. Instead of allocating more funds for long-term care beds, the minister is seeking to punish doctors, he said.”

A climate of fear is not the way we improve. If there’s indeed a bottleneck in long-term care beds, as I heard about in Ontario, that needs to be addressed. The province is already allocating more funds for long-term care, but will that be enough?

If there’s fear of punishment for not hitting the target, it’s likely these things could happen:

  • Doctors might delay writing admission orders, if the 24 hour time starts ticking when the order is written
  • Patients might be inappropriately discharged or transferred if that resets the clock
  • People might flat out fudge or falsify numbers and data
  • Hospitals might discharge patients to far-away nursing homes to free up beds (as suggested in this article)

The Montreal Gazette has this laugh-out-loud statement from a Health Ministry spokesperson:

“As the minister clarified today, the objective is not punitive,” Julie White, Barrette’s press attaché, explained in an email.

Not punitive? They are threatening to revoke the privileges of doctors… that’s not punitive?

Again, if the goal is improvement, fear and punitive measures are not the right path.

As Dr. Don Berwick wrote about in the New England Journal of Medicine in 1989, improvement requires trust and cooperation. Berwick learned the lesson directly from W. Edwards Deming that we must reduce fear if we’re going to improve systems.

Dr. Don Berwick on Respect and Change at the Front Lines – and Executive Levels?

Read more about what Berwick learned from Deming here.

Quebec has made great strides with Lean healthcare the past few years. I’ve enjoyed the few opportunities I’ve had to visit, teach, and learn. I hope a Health Minister making a bunch of noise doesn’t interfere with their real efforts to improve.

“Does the minister honestly think that the hospital managers and doctors want to keep patients in the emergency room on purpose,” Brunet asked. “Of course they don’t want to do that. The problem is that they can’t transfer these patients from the ER to hospital beds because 25 per cent of those beds are taken up with chronic-care patients.”

Of course doctors and managers are NOT intentionally inflicting frustration and poor care on patients. Chronic care patients might be another systemic problem to address as a better way of improving flow.

The Quebec government has posted a link to a case study about using Lean to improve emergency patient flow in Sweden.

How does lean work in emergency care?
A case study of a lean-inspired intervention at the Astrid Lindgren Children’s Hospital, Stockholm, Sweden

The lessons from that case study include:

  • Teamwork
  • Scientific problem solving
  • Breaking down silos
  • Connecting people

That’s the path I wish Quebec would take instead of blame, fear, targets, and threats.

Good luck to the fine people of Quebec in solving this important problem.

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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 book 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.

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4 Comments

  1. Hal says

    Among the many challenges I’ve seen over the years in healthcare improvement initiatives three stand out as evidenced in this article.
    1 – data is used as a weapon against employees.
    2 – improvement plans aren’t adequately resourced.
    3 – parent child relationship between “boss” and worker fosters fear

    1. Mark Graban
      Twitter:
      says

      Hal, sadly I’ve seen all of that too.

      1) I’ve long said, “Data should be used for improvement, not for punishment.”

      2) It’s not just “improvement plans” but “improvement needs” that aren’t adequately resourced. There’s a big gap, also, between the stated desire for a culture of continuous improvement and the reality.

      3) That parent/child dynamic also fosters “learned helplessness” and all kinds of other dysfunctions. One lab director I worked with was trying to change that culture through methods including “Family Systems Theory” (while acknowledging that directors and managers are not “parents”).

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