Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)
I received an email from a reader that I'm sharing and commenting on with permission.
“Dear Mark: I am a lean coordinator for a manufacturing company and it was a real shock to see some of the waste during a recent hospital visit to see a dying family member. He was 92 years old and had a DNR in place. He was having trouble breathing and a Rapid Response Team was called into place. Now, again, he was dying, so my first thought was that this seemed unnecessary. But, as they were preparing to treat them, the waste and confusion was obvious.”
At two different points, nurses (I think they were nurses) were opening their cart (which seemed like a good point-of-use inventory method) and they couldn't find what was supposed to be in there. Two different times, they had to leave the room to go find some tubing and to find some pads.
What is the point of the cart and the team if they don't have what they need when they need it???
Thanks for writing about lean healthcare. It was always just a curiosity, but last week's experience made this very concrete and real to me and our family.”
That sounds like an unfortunate situation, one that might have caused stress for the family and the hospital caregivers. Ideally, it should be viewed as a “nugget” – an opportunity for improvement so that came problem doesn't occur again. What is the root cause of why the cart wasn't properly / fully stocked?
It seems like it shouldn't be that hard to keep a cart properly stocked so that it's ready for use. If I were in the situation, I wouldn't go looking for blame – I'd look for process (or the lack thereof) as I've seen in so many healthcare settings.
- Why wasn't the cart fully stocked? Keep asking why and address actionable causes and root causes (don't look to blame an individual).
- Is there a formal process or standardized work for how the cart gets restocked after items are used?
- Note: Don't tell me “who” is supposed to restock it (a specific name), tell me the process that ensures this happens regardless of which individual is working that day.
- How do we know if the process is being followed? Is there a management checklist or verification to ensure that the cart has been restocked?
- Are spot checks done at the start of the day or shift to ensure that the cart is ready to go when needed?
- When there is a problem (such as missing tubes), what is the follow up other than running to go get the missing item.
- Are we moving from only fire-fighting to also focusing on prevention and process improvement after the “fire” is out?
The questions I'll pose for you, the readers:
- If you have direct ongoing experience working with RRT carts, what process do you use to ensure 100% availability of items?
- If you're generally a Lean person, what others questions am I missing?
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One additional question comes immediately to mind – Is the task of this RRT cart highly specified? Which leads to – is that specification known, visible, trained, etc.? Were those tubes really supposed to be there? or was someone just hoping there were some in the moment of crisis?
You can’t have the “right stuff” on board for every possible situation, so you need to know exactly which situations and circumstances you are preparing for. Conversely, you will know that you may need to go outside the drill when faced with an situation that is outside the planned scope of the prepared cart.
This may not be an issue in the current case – it sounds as though planned materials were just not there, though it’s possible that the searching in the cart was based on individual expectation, not an established standard for what should be there.
A high degree of specification also lays the ground work for improvement. PDCA will lead to better cart design as problems occur, but only if the plan is well specified and visible.
As “systems-oriented people”, readers of this blog are likely to go right to what appears to be the fundamental issue: why isn’t the cart stocked?
But the danger of doing so is that this question automatically leads to tension between stakeholders. Mark tries to defuse this possibility by noting that we shouldn’t look to “blame an individual” or find “a specific name.” Even with these disclaimers, however, it’s hard to see how anyone wouldn’t get defensive with this line of questioning.
Instead, what if we change our approach from finding the cause (which effectively translates to “who to blame”) to instead using the event to empower stakeholders?
This would be asking the nurses:
Lean is supposed to include as its second pillar “respect for people.” But even the tone of the original reader submission implies accusations of incompetence. Is it possible that the cart was fully stocked and that this particular situation required exceptional equipment? Doesn’t suggesting that there’s “no point” to the rapid response a sign of lack of respect?
The answer here is not to go looking for root causes, but to empower the people who are knee-deep in the situation with the authority and responsibility to make changes. In a culture where there is no jidoka (authority by anyone to stop the the line and deal with a quality issue), the words of an outside reviewer will only create frustration.
Hi – I’m the guy who sent the email to Mark. I’ve participated on here before, but don’t want my name on here about this issue, especially since I’m not trying to call out that hospital as being uniquely “un-Lean.”
I didn’t say there was no point to the RRT, Robby. I asked what is the point of the cart (the hardware) if the process isn’t as good as it can be. We can be hard on the system (it sucked) while realizing the individuals were all trying hard.
It was only my impression (I didn’t want to butt in as an outsider, trying to show respect) but it the language and expression from the nurses made it pretty clear this was a common problem that these items weren’t in the cart. To Andrew, yes, maybe it’s a communication or awareness issue, but the system sucked – it wasn’t performing the way it should.
Now, my relative was an old man who was dying. No harm came to him because of this bad system, but if it were me, in my 50’s recovering from a surgery and I suddenly had breathing problems, I wouldn’t want to die because of people scrambling around.
I’m sure Dr. Deming would hold the CEO of this hospital accountable for quality. I don’t think finding a root cause necessarily leads to blame, as Robby said. The CEO has a responsibility to ensure good processes (and this is not simply blaming the CEO).
I respect the thoughts you all have added, but I think the ultimate “respect for people” the hospitals should be looking out for is the patients and their families.
Two issues, not just one. Others can talk about the RRT cart. My questions is what is the purpose of the RRT? If they are there to save someone in distress, they were the wrong team. The patient had a DNR, so a “hospice-type” response was needed to reduce pain and maximize comfort.
Perhaps the RRT was structured for that purpose as well, but as the spouse of a former hospice nurse, I can tell you that medical staff trained to save lives usually do very poorly at comforting while letting people die.
Starting with the problem root-cause; I’d form a SMED Kaizen Event identifying the internal & external setups of the process. Then, standardize work instruction for each internal & external setup. However & unfortunately, it appears that the process of implementing a RRT when DNR guidelines have been established, appear as WASTE, possibly in the eyes of Medicare (if involved as the healthcare payor). This may result in additional cost to the family, if denied. Healthcare facilities are currently under enormous pressure, financially, & I only see this is another way to add additionally billings for services rendered by upper management. I’m sure if this facility was involved with Lean Enterprise, it would not have intervened with a RRT, when a DNR is associated with a patient.