How Can a Story Like This Occur in Any E.D., Yet Alone a Hospital With a Lean Program?
This story was sent to me by somebody I know with a Lean manufacturing career. It's shocking, but it could happen anywhere, I suppose. I'm not going to name names… the author of this has allowed me to share it, without mentioning him or the health system.
How can something like this happen in any hospital, yet alone one that has had a “Lean program” for a number of years?
What questions would you ask about their priorities and approach to Lean, given this story? Do they have the wrong focus? Are they maybe not changing the culture and the management significantly enough? Have they just not fixed every problem in their health system yet? Was the Emergency Department having a bad day?
How does a hospital fix the systems and processes that lead to these scenarios without blaming so-called “bad apples” or throwing people under the bus?
We can only speculate… but I'd be curious to hear your comments or questions.
We moved late last year to an area that was equidistant between two hospitals that are part of two competing health networks. Both are big hospitals, with good reputations.
On the night of my wife's emergency, I needed to choose which hospital to take her to, and I chose the hospital I knew to have started a Lean program. I knew this because I was offered a position by the head of their Lean program about a year previously, but chose to pursue a different opportunity.
They heavily advertised their “15 minute ER pledge,” so I thought that was the best option for getting her seen quickly, given that she was in extreme pain from a torsed ovary. She's given birth to four kids, two without pain management, and nothing had ever come close to this level of pain.
Needless to say I chose the wrong hospital. Highlights (or lowlights) from the night include:
No one would help me get her from the car to the front door. It took 15 minutes, and I had to eventually carry her.
No triage at the front desk. She had a potentially life-threatening condition from the risk of hemorrhage, but a guy with a sore knee and a kid with a cold were taken before my wife.
No pain management for over three hours, even after she lost consciousness several times. Nurse said they had recently implemented a new EMR system and things just took longer because they weren't trained properly.
Speaking of the nurse… she gave zero care to my wife other than doing her charting. When she vomited from the pain, I had to clean her up and help her with the gown while the nurse watched. She then told my wife, “It wouldn't hurt so bad if you'd stop screaming so much.”
No radiology technician to perform the ultrasound needed for the diagnosis. We had to wait until one was called in from home.
No surgeon to perform the emergency surgery she needed. They wanted to transfer her to another hospital in their network about 30 minutes away.
And, despite he severity of her condition, we didn't see a doctor until we were ready to leave the ER. He apologized for being too busy dealing with other emergencies on our way out, forgetting he spent at least 45 minutes earlier in the night directly across the hall from us talking tennis with the guy with the sore knee.
Luckily, when they told me they wanted to have her transferred after the diagnosis, I was able to reach her OB/GYN. Despite it being 3 AM, he had her transferred immediately to the hospital he operates out of — the one I should have chosen to begin with — and that made all the difference in the world.
For six hours at the first hospital, her pain was not under control.
When we arrived at the second hospital, her doctor met the ambulance at the door, medication in hand.
The team worked like a well-oiled machine. It was absolutely amazing. In 15 minutes, her pain was under control and two of the team members worked with me to collect her information, while the others helped prep her for surgery. Everyone knew their role and she was taken back to the operating room in short order. Surgery went well, but but the ovary had to be removed due to the long time without blood flow (which turned out to be a godsend once the pathology report came back).
I got to speak later to the head nurse on the team who prepped her for surgery and commented on how well they worked together. I asked if he ever heard of Lean, but said was familiar but they didn't “do it.”
So, I posed the question to him of why he thought there was such a difference between the two hospitals.
What he said really stuck with me. He said that they were just as short-staffed as the other hospital and worked just as long of hours, but that they were a TEAM. He said the people on the team worked the same days/shifts in general and played the same roles day in and day out. And that his role as the leader of the team was to help hem work together so that each person on the team could play their role a little better each day.