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.