Mike Radzienda writes…

Over the past ten years, hospitals have been bombarded with external regulatory mandates aimed at improving quality of care.  Amidst these challenges, payer mixes have dwindled and operating margins have narrowed.  This has left hospitals few resources for implementing thoughtful and robust quality improvement infrastructures.  As a result, hospital COOs struggle to develop meaningful partnerships with physicians who can effectively advance the local QI agenda.

Due to a dearth of availability and leadership in the traditional physician staff model, hospital administrators have taken on this QI agenda. This tactic has failed by design in that the key process improvement and quality improvement areas focus on the domain of clinical care, and at the micro-system level.  This end user microsystem is poorly understood in the C -suite.

In order to truly understand the healthcare delivery machine, one must experience it.   There is no better-qualified clinician to assume this task than the hospitalist.

By forging relationships with nurses and allied health professional at the microsystem level, hospitalists understand the details of complex hospital operations.  In essence, the hospitalist ‘s most valuable tool is her understanding of these intricacies.

An experienced hospitalist may rapidly assess microsystems and their interrelationship.  Although systems engineering theory can help organizations to prioritize initiatives aimed at process improvement; it is through the application of Chaos theory that hospitalists make sense of the healthcare delivery process.

To adapt a familiar metaphor, “A butterfly flapping its wings in China affects the New York stock exchange:” Hospitalists understand that the local health-system is a complex organism whose operations are inextricably linked by the human condition.  I will illustrate this in an anecdote entitled “Tube Wars:”

A common complaint of the hospital’s administration was that doctors were discharging their patients too late. This practice led to significant throughput problems and ultimately to ED diversion.  One of the physicians’ many explanations for this problem was that lab work was reported too late in the day; if they had lab data earlier, they could make discharge decisions earlier.

In an attempt to enhance the timely reporting of lab results, a hospitalist interviewed some of the key end users of the phlebotomy collection and delivery system at her hospital. She found that there was a system-wide work around put into place without the knowledge of anyone at the administrative level.  In the ideal workflow, a phlebotomist would show up to a unit with a list of patients whose labs were to be drawn. Then after every third patient was drawn, the phlebotomist would send the blood to the lab via the hospital’s pneumatic tube system.  However, what she discovered was that instead of sending the blood after every third patient, the phlebotomist was waiting until he had drawn the entire floor’s labs before sending the blood en masse.  This meant that a lab draw ordered for and drawn at 6 a.m. might not arrive in the lab until 8 a.m. (it takes 2 hours for one phlebotomist to draw the entire floor).

This particular hospitalist had some training in process improvement methodology, and decided to adapt the “5 whys” approach to understand the root cause of this work around.  She discovered that the phlebotomists batched the blood because there was a pneumatic tube shortage! It just so happened that in the early morning hours, another key healthcare delivery process was competing with the phlebotomists’ ability to deliver blood.  The pharmacists were using the pneumatic tubes as well in order to get morning medications dispensed from the central hospital pharmacy.

This “Tube War,” as the staff aptly coined it, was so pervasive, that even nurses had taken steps to secretly horde pneumatic tubes.  Apparently there were so many processes dependent on the pneumatic tube system, that the end users had developed a sub-routine allowing them to maximize their own efficiencies at the expense of another end user’s efficiency.

Drilling a little deeper, the now very intrigued hospitalist, discovered that the there was no defined process for delivering a tube back to a unit from whence it came. This meant that once a tube was sent into the system, chances were it would never be returned.  As a result, individual patient care units adapted their own unique process for retrieving tubes, saving tubes, hiding tubes, etc…

Due to the efforts of this one hospitalist who was able to put the pieces together, the “Tube Wars” ended and there was a significant improvement in lab turn around time as well as other tube dependent processes.

So please, CMOs, COOs, VPMAs, CNOs, tap into your hospitalists! They know how the system works at levels you could never imagine.

And everyone lived happily ever after….THE END.

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