Wednesday, April 04, 2012

Going to gemba at Jeroen Bosch Hospital

Knowing I was going to be in the vicinity after TEDx-Maastricht, I contacted my friends at Jeroen Bosch Hospital to ask if I could be of help as they pursue their impressive quality and safety journey.  The timing worked out that I would address a new leadership program for operations managers at the hospital, run by Miriam Casarotto (at left) and her colleagues.  The main topic was transparency, which I presented as a tool that assists process improvement.

I have been trying to go to gemba when I have speaking engagements like this, spending time on the floors of the hospitals I visit to get a sense of how work is organized.  Doing so also often provides some examples that make my talks more relevant.

A nurse named Kimmie, on one of the surgical wards, was kind enough to let me shadow her for a while.  (At first, she tried to keep explaining things to me.  I had to tell her that I just wanted to observe what her work life was like, and to try to forget I was there.  Why?  Well, if people keep interrupting their work to tell you what is going on, you don't get to see the normal flow of events.)

Anita Tucker at Harvard Business School has conducted studies of how nurses spend their time and has found that they often spend time overcoming obstacles they encounter.  Those work-arounds are effective in the short run, permitting the nurses to carry out the tasks at hand, but root cause problems are often left unsolved.  Over time, this has created an environment in which nurses are unlikely to spend more than 20% of their time taking care of patients, using the rest on administrative matters and, more likely, fetching or solving problems over and over again.  It is an environment ripe for systemic process improvement, but such improvement is often slow to occur, if it ever occurs.  This is certainly not the fault of the nurses, who are caring and well-intentioned.   The underlying problems lie elsewhere.

It is a remarkable thing, but within five minutes or so of starting to shadow a nurse in almost any hospital, you see this phenomenon.  Kimmie was working on discharging a patient and need to have a physical therapist visit the person before he was permitted to leave.  Here you see her faxing the PT order to the appropriate office.

But then, immediately after, she called the physical therapist to arrange for the visit.  After I had finished my shadowing, I asked her what that was about.  Well, she needed to have the PT visit occur today, and the fax order would not be viewed by the PT before the day was over.  Hence, she had to call the PT on the phone to put in that request.
So, Kimmie had to duplicate her work, taking up precious minutes of her time.  She also had to interrupt the therapist, wherever that person was located, wasting precious minutes of his/her time.  This particular instance of waste may not be that significant in the big scheme of things, but when it is multiplied by hundreds of other examples and by hundreds of people, you can see that there is a large cumulative impact.

An article about Professor Tucker's research put it this way:

By quickly and effectively solving the many small problems that came up throughout their shifts, the nurses Tucker observed continued to provide excellent care to their patients. 

The bad news, said Tucker, is that the root causes of the problems - from annoyances like supply shortages to potential dangers like unclear instructions - went unaddressed and thus continued. 

I later told this story to my seminar audience.  (Some physical therapists in the audience smiled knowingly.)  My point, of course, was not to critique this hospital.  Jeroen Bosch is a very fine place with excellent, well-intentioned people.  It just happened to be where I was when I went to gemba.  Check out your place, and you will find the same phenomenon, writ many times over.


Unknown said...

It seems that there is no structure for forward thinking in the nurse occupation. Even if a nurse has an answer the way the union is setup there is very little possibility of advancing the processes of how hospitals are ran.

Anonymous said...

The frustrating thing about your observations is that, indeed, the identical problems occur in practically every single hospital, be it in nursing, lab, radiology, surgery or whatever. And yet every hospital reinvents the wheel trying to solve the same problem that the hospital down the street is also working on. This seems so wasteful in itself.


Paul Levy said...

Dear unknown,

I don't think this has much to do with a unionized versus non-unionized setting.

Annemiek said...

Some of the most frustrating things of work. Yes, you learn to work around it, but it shouldn't have to be. Thing is, after doing it that way for a long time you get used to it and don't even notice anymore that it should be different.

Anonymous said...

As to Unknown's comment; I never worked in a unionized hospital, but I could see some potential for delay in process improvement, if union work rules/job descriptions and misplaced concern over preserving jobs came into play. It would require extra education of the staff by senior leadership, perhaps.