Thursday, June 25, 2009

Interns Learn Lean -- They get it in two days!

With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.

Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."

Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.

To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!

To highlight the less efficient aspects of the patient discharge process from a nursing perspective.
To provide a standardized patient discharge protocol for the nursing staff.
To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.

Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.

Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.

The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.

Medication reconciliation:
At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.

Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:

At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.


New Internal Medicine Intern, MD said...

What a great idea to involve interns in QI as soon as they start! Who better than untrained, intelligent eyes to critique inefficient actions? I wish I were involved in something like this my first couple of days of orientation, rather than sitting for hours on end listening to corporate propaganda.

Anonymous said...

This is a great idea and, of course, discharges are known to be problematic in all hospitals.
However, just reading this and thinking that all those observations were made so quickly by 3 relatively untrained people makes me wonder - exactly why is it that our government doesn't feel that reforming the processes and systems of health care would save big bucks???!!!! It seems like requiring hospitals/practices to start process/system reform immediately, rather than wating weeks arguing over a public vs. private insurance plan would begin producing immediate results, rather than the gridlock we always see in Washington. Grrr!!

nonlocal MD

Paul Taylor said...

Ozarks Community Hospital Vision for Change: Visit the OCH Health care blog to read our health reform plan.

Ray Brown Scholar said...

This was a great idea and should be piloted by other institutions. I am the practice manager for a pediatric hospitalist program in Florida and we are currently in the process of updating our resident orientation manual to include a section on "How The Residents Can Impact Hospital Throughput".

Anonymous said...

Great idea. Many hospitals now have a residency program for RNs. Have you thought about doing something similar for them?

PookieMD said...

I have sometimes been critical of your blog as you don't appear to be in the trenches, and have a top down approach. Medical students, residents and attending physicians are trained to do medicine. I advocate that we physicians learn about QI, through-put, LEAN, kaizen etc., but ask, "WHEN?" Medical school is already 4 years, and the shortest residency is 3. I think it is important that we lead this charge, but sometimes resent it when administrators come at me with the latest improvement strategy, with out ever asking for input from those who will actually implement these strategies. I think those IN the health care trenches are best fit to implement change, but sadly, the least likely to do so.

Anonymous said...

I think you completely misrepresent my approach, which is anything but top down. The whole idea of Lean and BIDMC SPIRIT is that change is driven from the people on the factory floor (i.e., gemba). It was the MDs who asked for this training, and the interns love it.

76 Degrees in San Diego said...

You get it. And, you have a cohort of high achievers. Onward, upward!

Anonymous said...

To Pookie MD;

Unfortunately, your attitude is shared by many MD's (e.g. QI is way down on the priority list compared to other things), which is precisely why MD's are NOT leading the charge and having the administrators come to them instead. Why don't you go to your administrator with some QI ideas?
As for WHEN, it should be incorporated into the medical school curriculum in the second year with didactic instruction, reinforced by day to day exposure during clerkships, internship, residency, etc. Paul is starting this at the lowest level he can, which is the intern right now. Frankly, I think Harvard is missing a huge opportunity to model a new medical school curriculum which would incorporate these precepts. They wouldn't have to lift a finger to find people to teach it in Boston, with the IHI, Gawande, Paul, and numerous other knowledgable people. But no one likes change, least of all medical bureaucrats.....

nonlocal MD

Andrew said...

Paul, Pookie MD, et al,

Lean is driven from the front line, but does require buy-in from the top (which is clearly present at BIDMC). A favourite quote is "change done to us is debilitating, change done by us is exhilirating".

Administrators have to be bought in on QI and Lean initiatives to make them sustainable. I've interviewed a great many lean healthcare experts in the past 6 months and have heard over and over that lean training without buy-in across the organization is sub-optimal. Teaching lean tools to people on the floor can yield great results, but the tools can also remain localized to the individual. To complete a transformation, change management needs to be applied.

We were engaged to co-develop a simulation based on this requirement. See:

Lean training for professionals at Ontario hospitals includes this change leadership simulation as a part of the lean curriculum so lean efforts become sustainable. A big part is engaging people "at the top" and "in the trenches". You need leaders in both places.

PookieMD said...

Anonymous, and Mr. Levy,
How do you know I DON'T go to my administrator with QI ideas? Having an intern think about QI for a day or two is hardly ground up! My point was that medical schools and residencies don't have time to teach this, AND THEY SHOULD! However, I know that in my daily rounds as a community hospitalist, it is extremely hard to get through the work of being a physician, and that I have little time to even think about QI. I would like to see Mr. Levy outside of an academic setting and in the trenches--this is not to belittle his ideas, but to bring them into a stronger lens. I am a fan of Mr. Levy's blog, and have actually noted this in my own blog. I do believe in realitiy testing, however.

Anonymous said...

Are we all agreeing or disagreeing? I'm losing track!

Andrew said...

Agreeing... I think. I was merely challenging the PookieMD remark that I felt implied that an administrator's involvement in front-line activities is a negative thing. It's necessary to perpetuate involvement from administration!

Anonymous said...


The question to ask is "why". If you are stuggling through rounds and physician work, what is the disease in the process that makes it that way? Diagnose your work like you do your patients and get to the root cause.

If you are stuggling through your work you don't have time not to do PI projects (since QI and PI are the same thing)

Anonymous said...

Actually, ask "why?" five times to get to the root cause.

Jen said...

This project is a great idea! I am a first year ID fellow, having just completed my pediatrics residency. I also have a specific interest in learning about hospital administration and QI. As residents, we learn almost nothing about these aspects of practicing medicine, and many doctors feel ill-prepared to function well in the "real world" after leaving their formal training programs. It is great to see residents being involved in the hospital improvement process, as it seems to me that QI represents the most seamless interface between medical practice and the "business of medicine." The goals of patient safety and better medical care are shared by both physicians and administrators - why not start learning this process when we begin our training as physicians? I look forward to hearing more about this project and maybe adapting some ideas to present to our residency program as well. Thanks!

Unknown said...

I applaud yours and ACGME’s work to integrate healthcare improvement early in medical careers.
After more than 20 years in Critical Care I now would like to engage full time in the PI environment. What suggestions do you have for those of us in mid-career to identify opportunities (& progressive institutions) to learn beyond our first hand experiences and participate in healthcare continuous improvement?

Anonymous said...

Contact Maureen B. at the Institute for Healthcare Improvement. They have a fellowship program there that is excellent, along with other such things.