A Pharmacy's Long Turnaround Time?

Star-Telegram.com: | 05/06/2008 | LETTERS

OK, so we're piling on JPS Hospital at this point.. but this letter to the editor caught my eye today:

One glaring omission in your series was failure to critique the pharmacy. It's one of the worst parts of the JPS system.

One example: The pharmacy won't let us order refills until five days before our medications run out. But it often takes seven days or more to get the refills. Some patients need a continuous supply of life-or-death medications. The pharmacy seems to operate independently, with an air of indifference, as if it's not part of a patient-care facility.

I hope your series will prompt those officials in charge to act aggressively to fix the hospital's problems so you'll have plenty of material for your series on JPS's positive aspects.

Yikes. That's one anecdotal story, but still. A pharmacy's "value added" time (filling a prescription and having a pharmacist review) should really be measured in minutes, if not seconds. It shouldn't take one day, let alone seven, to get a prescription filled.

A standard Lean measure is the percentage of "Value Added" time to the total "cycle time" or "turnaround time." As with many non-Lean processes (whether in manufacturing or healthcare), the percentage of VA time is very low according to that story about JPS. The non-value added time is waste -- waiting due to not having enough capacity to get the work done or waiting due to batching and other systemic delays.

I certainly do hope there are JPS success stories in the future. Lean methods could certainly be used to improve processes, reducing turnaround time in the pharmacy.If there isn't enough capacity (people or equipment) to get each day's work done, Lean would focus on reducing wasted time so people can be more effective. Lean isn't about cutting corners or doing work too fast -- that might introduce more errors, something you don't want to do in a pharmacy, yet alone any process.

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Problems at JPS Hospital, Part 2

Star-Telegram.com: | 04/28/2008 | Trapped in a waiting game at JPS

Update: For those who didn't catch the update to Monday's post, it was announced that the CEO will be leaving, with somewhat of a sliver parachute, I guess.

The first link above takes you to the Monday article in the series about a Fort Worth TX hospital. This article focuses on problems with patient throughput and access:

"I think the emphasis is totally on money. We've forgotten what our mission is: to take care of indigent patients," said Dr. Wayne Williams, a JPS board member.

The first anecdote in the article is about a patient who allegedly died as a result of poor ER care:

Yet JPS' emergency department is as clogged as ever -- worse if measured by the time patients must wait for care. The crowds aren't as obvious, though -- they've been moved out of sight.

Doctors and nurses say quantity, not quality, is the JPS measure of healthcare, a concern echoed by consultants who studied JPS operations last year.

Like the employees who "gave up" (as mentioned in the first article), so do patients:

"It becomes a vicious cycle for those patients who know they have a difficult time getting access to the JPS system," said Dr. Greg Fuller, president of the Tarrant County Medical Society. "So what happens is they give up before they even start seeing a doctor. When they finally get seen by a physician, it is sometimes too late to alter the outcome of what has happened to them medically."

Bottlenecks permeate the health network at every level. Patients wait weeks to get a doctor's appointment and months for some specialists, like pulmonologists. And when appointment time finally arrives, patients cool their heels for hours waiting to see the doctor.

The hospital is focusing on physician productivity, but in a way that apparently sets quotas. We should remember from our Dr. Deming lessons that setting quotas will inevitably harm quality, as people are pressured to focus on quantity over quality:

Steve Montgomery, chairman of the JPS board, said doctors need to speed up to match the pace in the private sector.

"Why can't they see more [at JPS]? Why are some of them seeing 16 patients a day when private doctors are seeing 30 patients per day?"

There's a ready answer from physicians and other staff: The health problems of the poor are far more complicated. What's more, medical care at an educational hospital, such as JPS, can take longer because the doctors in training are learning as they go.

Dr. John "Jay" Haynes, the chief medical officer at JPS, said the productivity standards do consider the patient's age and severity of cases.

But other doctors object to mandates to see a set number of patients per hour in some departments, clinics and other JPS facilities. Such quotas have nothing to do with quality of care, board member Williams said.

"It hurts quality care," he said. "And it is a mechanism whereby they can blame the doctors if there are access problems."

Disorganization leads to wasted employee motion and delayed surgical procedures:

Once in an operating room, things slowed even more. The operations manager ran around trying to find missing equipment and instruments. Nurse assistants, tied up transporting patients, weren't checking the operating room and making sure needed supplies were available.

Those are problems that are 100% fixable, using Lean methods of 5S, standardized work, and waste elimination.

Here's what the consultants identified as caused of delays (with my comments):

1. The hospital doesn't have enough beds, so patients stack up throughout the hospital (what can be done to reduce length of stay? more efficient discharge processes? faster lab results?)

2. Medical records can't be found or aren't up to date (bad processes/systems)

3. Medical equipment and instruments are broken or in short supply. (lack of systems/management focus)

4. Doctors are juggling work in clinics, the operating room, hospital rooms and the emergency department.

5. Some nurses lack experience or are diverted to hunt for supplies. (poor training, 5S, and standardized work)

6. At peak times, there's not enough staff (need to eliminate wasted motion or staff to match demand)

7. Some employees lack the skills or are otherwise unable to do their jobs (poor hiring or poor training)

8. It takes too long to clean and ready operating rooms and hospital rooms between patients (need to use Lean to reduce setup time, reduce wasted motion... better standardized work)

9. Doctors don't get timely consults from specialists or crucial results from labs. (need to reduce batching or improve standard processes?)

10. Inadequate phone systems, a limited window for scheduling appointments and communication problems between the clinics and call centers make it difficult to get in to see a doctor or talk to a nurse.

A commenter asked about Part 1 of the JPS articles, did I think Lean could fix the mess? No, it runs much deeper than that. I hope a real "servant leader" type will take over though, one who can listen and actually start getting people to work together. The community needs it.

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Updated: Problems at JPS Hospital, Part 1

Update 5/1/08: The CEO is being forced out, "retiring" in September

Star-Telegram.com: | 04/27/2008 | JPS patients get shortchanged as cash surpluses keep growing

Secondary article summarizing some of the problems

I linked to this on Monday and I'm revisiting it to quote and comment on the first article of the series of articles about problems with JPS Hospital in Fort Worth.

The first article questions why a taxpayer-supported, not-for-profit hospital has a large surplus (another term for profit) yet is deficient in terms of having working equipment, space, and staff to properly care for patients who come to the "safety net" (meaning people who have no place else to go) hospital.

Boosted by tax funding other local hospitals don't get, JPS has been racking up fat surpluses -- nearly $97 million last year alone. But the cash has not helped a dedicated core of doctors and nurses overcome the system's callousness, ineptitude and filth.

Ouch. The paper's words, not mine.

Overwhelmed nurses no longer ask for the help or equipment they need, resigned to the fact that management won't listen.

"The system will transform you, so you either leave, do less than the kind of job you would like to do, meaning you have to spend less time with patients or you have to be curt because you know there is a never-ending cascade of people," said Dr. Bernard Rubin, a JPS board member and network physician.

Again, ouch. I've heard this before in some hospitals, that employees and staff don't feel listened to. That's something we work to turn around in Lean engagements -- getting administrators to listen to their staff, engaging them in improvement efforts, working more toward becoming "servant leaders." It's bad when nurses have gotten to the point of "giving up."

Administrators commissioned a consultant report that outlined deficiencies:

Even Houston-based consultants hired by JPS to study the efficiency of the hospital and clinics last year were struck by the coldness.

"Where's the caring and compassion?" asked observers from InSight Advantage, which detailed hospital conditions in nearly 600 pages of reports.

The reports were authorized by hospital administrators and cost $657,618 plus expenses, but were never presented to the JPS board. The Star-Telegram recently obtained a copy.

You'd think if you spent that much on a consultant report (not IMPROVEMENT, but just a REPORT), the CEO would be interested in the findings.

When Cecero was asked about the reports' findings, he said he couldn't answer: He hadn't read the documents or been briefed on them.

"I don't think it's my job or my role to read every report that comes through this organization," he said. "That's why we have an executive team."

What??? What a ridiculous abdication of executive responsibility.

Some more details:

Some JPS doctors explained in the survey why they wouldn't recommend the hospital. "Dignity can't be present with a small room and no curtains. The ER situation impacts this; Foley [catheter] bags showing, beds against hallways, legs hanging out, etc.," one physician wrote.

At the "Rapid Assessment and Treatment" area of the emergency department, at times 45 patients were jammed into a room with chairs for 19. The space was hot and reeking. Patient privacy was not a remote possibility, InSight reported. (See supporting document as PDF.)

"What is even more concerning is the acceptance of these conditions by management and the staff," the report says.

To counter negative opinions, JPS hired patient advocates for the emergency department. InSight called that move "sad" and a waste of resources -- customer service should be everyone's job.

That last part sounds like something Deming would have said. "Patient advocates" typically respond to patient complaints after the fact... trying to soothe over situations. I think the consultants are right that the money would be better spent on preventing problems from occurring.

In the Short Stay Unit, InSight reported that some patients spent 10 days in a hallway bed, with only a thin curtain to separate them. Up to 26 patients shared one bathroom with one sink, one toilet and no shower. Patients not strong enough to go to the bathroom had to share one portable toilet.

As for basics like thermometers, wheelchairs and IV poles -- there weren't enough to go around.

Cynthia Brannon said her sister spent a week and a half in a hallway bed waiting for surgery.

Yes, the "Short Stay Unit" is very inaccurately named. If the hospital has a huge surplus, it's a shame that they don't have enough basic supplies (or such poor organization that they can't be found). Mattresses are stained and torn, which creates infection control problems -- problems that can directly lead to patient deaths.

There are problems in the O.R. -- significant cleanliness and safety issues:

In endoscopy, where doctors look at internal organs using a scope, a patient was treated in a room that hadn't been cleaned from a previous case. That's a serious error, said Dr. C. Glen Mayhall, who studies infectious diseases at the University of Texas Medical Branch at Galveston.

Likewise, "on more than one occasion," nurses didn't realize an operating room hadn't been cleaned until they were preparing for a patient and saw blood, bone and globules of fat on the floor, the wall and the wheels of carts, InSight Advantage reported. (See supporting document as PDF.)

The CEO commented:

Cecero said that JPS has the best interests of patients at heart but that mistakes do happen. "When you see the volumes of patients we're seeing, with some of the inadequacies of our facility, it's going to happen. It's going to happen in any hospital," he said.

That really sounds like excuse making, doesn't it? Is it inadequacies with the facility or inadequacies with administrators? I know I'm being tough on JPS, not having walked in their shoes.... but you'd have to think things COULD be much better there. Is there any need to have "squalor" in this country, in any hospital? Sure, every hospital has complaints and hospitals can't just spend money blindly -- they need to run a surplus to be able to invest in their future. But it sounds like JPS isn't investing in today's needs -- safe, compassionate, quality care. Sad.

As with many articles like this, the reader comments are interesting reading, as well. If you think I'm being hard on their leadership, take a look. The number of readers calling for the JPS leadership to be fired (or accusing them of bribing Congressmen and othe) far outnumber those who say the paper is being too hard on the hospital.

Some hospital staff members are commenting how we shouldn't blame the staff members. I'm certainly not. When people bring safety concerns to management and they're not acted on, that's a crying shame. It's understandable why employees would get "hardened" and be "rude" in a bad environment. The culture and attitudes are set from the top.

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Trouble in a Fort Worth Hospital

JPS patients get shortchanged as cash surpluses keep growing

This linked article is a preview of what I'll be blogging about next. I'm trying an experiment in posting an article first... what comments do you have? Don't worry, I'm not totally outsourcing the blogging to the readers :-)

What a mess. Reading stuff like this will help you see the opportunities for Lean -- well, it's not just "Lean" but some good leadership. Maybe a mess like the hospital described in the article is beyond repair. It's embarrassing that this is the local county hospital in my area.

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