The Transport Dilemma
14/01/10 19:15 Filed in: Simple Lean Tools
The problem was enduring and well-known. This hospital ward admitted patients around the clock, sometimes from the Emergency Department and sometimes directly from doctors. As the patients came in they were assessed and if they needed emergency scanning (x-ray, MRI, etc) they were sent. But the bulk of the patients waited until the day shift if they could.
As the patients were assessed their needs were entered, where possible, into the computer record. So, for example, Patient 1 would need an MRI in the morning, he was able to sit up and didn’t need oxygen for transport. This information was important for the transport team who would arrive on the ward in the morning with the required equipment. It looks like a system that should work well, but there were some problems.
1. The computer screen had no place to record the need for oxygen.
2. The condition of the patient could change dramatically in the hours between assessment and transport.
3. These two problems meant that a full-time person in imaging was required to call the ward to determine the condition of the patient before sending the transport team. They would bring oxygen if needed and send two people if the patient couldn’t travel by wheelchair and needed to be pushed in their bed
4. The receptionist on the ward would start receiving calls the moment she walked in. She didn’t know the condition of the patients because she had just arrived at work, so she had to run around and ask the nurses The nurses would then have to interrupt what they were doing to find out and answer. This would usually continue for 2+ hours as the night patient backlog was worked down.
We set up a Simple Lean meeting but couldn’t get all the players. We got the second-in-command from imaging, the receptionist from the ward and someone from the transport team. We didn’t have a doctor or someone from IT. That meant our solution had to leave these two groups out. We couldn’t solve this by asking the doctors to do something different (like finding a place to put the oxygen requirements or re-do assessments closer to the time of transport. We couldn’t ask IT to add a field for oxygen needs or magically produce handheld devices so nurses could update patient condition at the bedside.)
We began by writing the problem on the flip chart. “Changing condition of patients and incomplete information mean we are spending too much time on the telephone trying to determine what people and equipment to send for transport. Even then we sometimes get it wrong and send to much or too little.
After we had the problem up we began looking at ways we might solve it. We started by running through recent transports scenarios. By talking through the situations we began to feel comfortable with the various problems and how they arose. The first half of the meeting was meant to record possible solutions that would then be tested in a Small Test of Change.
We slid inevitably into statements like, “If only the doctors would do this or that, we wouldn’t have this problem.” “If only IT could modify the program we wouldn’t have this problem.” We still would have, but it didn’t matter, we couldn’t brainstorm for someone who wasn’t in the room.
We got about 45 minutes into the meeting and it looked like we were going to have to re-schedule, when I saw a possible solution and began asking some questions.
The success of a meeting like this and the subsequent work depends on the participants owning the solution. It does no good for an outsider to solve the puzzle. You can only do it through questions. So I asked, “Is there a safety reason the ward can’t have its own portable oxygen? Is there room to store a wheelchair or two on the ward?”
If the oxygen and the wheelchairs could be stored on the ward, then the transport team could just send two people when the workday started. If the patient was bedridden they had enough people to move them. If they needed oxygen, they had it available.
There was silence in the room as they considered this possibility and someone said, “Can it really be this easy?” We set up the small test of change for the Monday morning--about 5 days away to give all groups time to communicate what was going to happen. We decided to try the Small Test of Change for two hours on that morning. We lined up extra help so we could quickly move patients if there was a problem.
Monday morning came, the transport team arrived. Two patients went by wheelchair, one with oxygen and one without. They brought the oxygen back when they came for the next patient and left it on the ward. The receptionist had no phone calls for the first hour and only a few for the second hour. None of them were from Scanning. She later confessed she was bored.
The scanning department had the use of one of their technicians who once had to be on the phone all morning. No patients had to wait for extra equipment or people and everything flowed. When we tried to stop the test at two hours and all the night backlog was through with their scans.
No extra money was spent, no extra demands made on people. Both the scanning tech and the receptionist were freed up to do other work. Everyone felt good about what they had done. The test started a new era of cooperation across the two groups who both felt the other had helped them end a frustrating and time-wasting process.
As the patients were assessed their needs were entered, where possible, into the computer record. So, for example, Patient 1 would need an MRI in the morning, he was able to sit up and didn’t need oxygen for transport. This information was important for the transport team who would arrive on the ward in the morning with the required equipment. It looks like a system that should work well, but there were some problems.
1. The computer screen had no place to record the need for oxygen.
2. The condition of the patient could change dramatically in the hours between assessment and transport.
3. These two problems meant that a full-time person in imaging was required to call the ward to determine the condition of the patient before sending the transport team. They would bring oxygen if needed and send two people if the patient couldn’t travel by wheelchair and needed to be pushed in their bed
4. The receptionist on the ward would start receiving calls the moment she walked in. She didn’t know the condition of the patients because she had just arrived at work, so she had to run around and ask the nurses The nurses would then have to interrupt what they were doing to find out and answer. This would usually continue for 2+ hours as the night patient backlog was worked down.
We set up a Simple Lean meeting but couldn’t get all the players. We got the second-in-command from imaging, the receptionist from the ward and someone from the transport team. We didn’t have a doctor or someone from IT. That meant our solution had to leave these two groups out. We couldn’t solve this by asking the doctors to do something different (like finding a place to put the oxygen requirements or re-do assessments closer to the time of transport. We couldn’t ask IT to add a field for oxygen needs or magically produce handheld devices so nurses could update patient condition at the bedside.)
We began by writing the problem on the flip chart. “Changing condition of patients and incomplete information mean we are spending too much time on the telephone trying to determine what people and equipment to send for transport. Even then we sometimes get it wrong and send to much or too little.
After we had the problem up we began looking at ways we might solve it. We started by running through recent transports scenarios. By talking through the situations we began to feel comfortable with the various problems and how they arose. The first half of the meeting was meant to record possible solutions that would then be tested in a Small Test of Change.
We slid inevitably into statements like, “If only the doctors would do this or that, we wouldn’t have this problem.” “If only IT could modify the program we wouldn’t have this problem.” We still would have, but it didn’t matter, we couldn’t brainstorm for someone who wasn’t in the room.
We got about 45 minutes into the meeting and it looked like we were going to have to re-schedule, when I saw a possible solution and began asking some questions.
The success of a meeting like this and the subsequent work depends on the participants owning the solution. It does no good for an outsider to solve the puzzle. You can only do it through questions. So I asked, “Is there a safety reason the ward can’t have its own portable oxygen? Is there room to store a wheelchair or two on the ward?”
If the oxygen and the wheelchairs could be stored on the ward, then the transport team could just send two people when the workday started. If the patient was bedridden they had enough people to move them. If they needed oxygen, they had it available.
There was silence in the room as they considered this possibility and someone said, “Can it really be this easy?” We set up the small test of change for the Monday morning--about 5 days away to give all groups time to communicate what was going to happen. We decided to try the Small Test of Change for two hours on that morning. We lined up extra help so we could quickly move patients if there was a problem.
Monday morning came, the transport team arrived. Two patients went by wheelchair, one with oxygen and one without. They brought the oxygen back when they came for the next patient and left it on the ward. The receptionist had no phone calls for the first hour and only a few for the second hour. None of them were from Scanning. She later confessed she was bored.
The scanning department had the use of one of their technicians who once had to be on the phone all morning. No patients had to wait for extra equipment or people and everything flowed. When we tried to stop the test at two hours and all the night backlog was through with their scans.
No extra money was spent, no extra demands made on people. Both the scanning tech and the receptionist were freed up to do other work. Everyone felt good about what they had done. The test started a new era of cooperation across the two groups who both felt the other had helped them end a frustrating and time-wasting process.