Monday, October 05, 2009

Kaizen Corner -- for lack of a battery

Mark Zeidel's commentary continued in late August with actual application of Lean principles.

As we move into our efforts to enhance the flow of patients from the Emergency Department to the medical floors, I have had the privilege of visiting with multiple people in the ED and Admitting. I have done Gemba’s at ED signout, with an ED core nurse, with an ED charge nurse, with Triage, and with the Admitting Office. I have been enormously impressed with the ability and dedication of these people.

At the same time, ED people are and will be, observing our admissions and patient care processes on the floor. From what I haveseen I have no doubt that we can reduce markedly the time it takes for many of our patients to transit the ED and reach the floors.

Last week we discussed Toyota’s approach to problem solving. We expand on this topic this week by describing how Toyota employees reach the root cause of a problem, with the goal of seeing that it never recurs. The idea is to keep asking why (the 5 why’s) until they discover the root cause, which is defined as that level of understanding that will permit development of a countermeasure that will prevent the problem from occurring again.

As an example:

Symptom: Mrs. Jones’s discharge was delayed for 3 hours until the medicine orders could be written.

Why #1? The intern could not get the orders written during work rounds, wrote down the medicines on a piece of paper, and did not have time to enter them into the electronic order
set until later in the day.

Why #2? Work rounds were rushed because the team needed to gather the data on each patient by hand.

Why #3? The team needed to gather the data and could not easily enter orders because the computer on wheels was not available.

Why #4? The computer on wheels was not available because its battery has run out and must be replaced.

Why #5? No one is responsible for regularly checking and maintaining the computer on wheels to ensure that it is always working.

An analysis like this would develop a standard that each team making work rounds must have (and use) a functional computer on wheels, and would assign the maintenance of the computer on wheels to appropriate staff. Coupled with this would be the expectation that the vast majority of orders should be written on patients by the end of work rounds, so that tests and discharges can occur promptly. We have a group which is developing Lean improvements to work rounds.


jgnat said...

Hi, I am a government worker in a completely different industry segment, but I do find many of the processes for improvement are the same. I've been interested in Kaizen for some time and I am grateful for the example you provided. We have a similar problem "for lack of a battery" - in our meeting rooms. A few years back we all rushed to get our rooms wired with computers and networked computers. Who takes care that the computers and remotes are all operating?

Anonymous said...

This is interesting, because every hospital I've been involved with has a problem with the ER-to-floor transfer issue, and spends inordinate amounts of time solving it. One of our hospitals even received the Baldridge (or Codman, I forget which is which) award for their efforts.
One would think the solution(s) could be encoded and stored in the Joint Commission's new Center for Improvement or whatever it is - so that each hospital doesn't have to start from scratch reinventing the wheel. The root causes and issues are much the same across the country, with individual tweaking.

To make this personal, my 87 year old mother had to wait 3 hours on the floor for her regular medication for a previous vertebral compression fracture, after admission from the ER to r/o stroke. Why? Because they had to again "put her in the computer" due to the discharge/admit system when a patient is transferred. This universal hospital glitch drives me insane and hurts patients! There's got to be a better way!!


Paul Levy said...


Our IT department does a fantastic job at that.


I sure hope so!

Anonymous said...

Here is another interesting way to look at ER overcrowding and patient flow. I guess this would be considered "why #6":


Andrew said...

I agree this is typical of every hospital I've ever known (I'm a hospitalist/internal med physician). The thing that may make a difference in BI's approach is having top-down involvement in fixing the problem. Otherwise, my reading of the scenario is, the intern needs to learn how to beg, borrow or steal a battery, needs to out- maneuver his peers for the use of the rolling computer each morning, and needs to be ready to give it all up when his next attending (next week, certainly no later than next month) decides that walk rounds are silly and he should be ready to read his presentation off a clipboard in a crowded side room.

Paul Levy said...


To be clear, while there is top-down involvement, that is for support, training, and encouragement. The actual problem solving arises from the ground up, and then grabs help from those layers needed all the way up.