Triaging in health care. Time for new thinking….

By | September 22, 2009

I grew up watching M*A*S*H. The last episode in the early 80’s became the most watched TV episode in American history. I have the image burned into my brain of Hawkeye running towards the 4077’th Mobile Army Surgical Hospital helicopter pad, ducking below the aircraft blades to assess the injured.

The show brought into popular imagination the drama of doing triage. Nurses and doctors working together to care for the many wounded ensuring the most severe conditions were treated appropriately.
As consultants working in health care process improvement, we see triaging happening all over the place. We most commonly think of “triaging” as an activity in the Emergency department, where a dedicated triage nurse assigns relative priority.

But it goes way further than the ER…
‘Triage’ occurs at mental health agencies, home care, addiction, hospice, primary care, community care access centres, and the list goes on. These scenarios have little in common with the battlefield triage conditions from which the term originates (apart from their sometimes chaotic surroundings).

What’s so different?
  1. It’s not war! There is no combat that drives a surge of patient activity. In fact, in many health care sectors, the pattern of patient demand is very predictable. We often know which days and which times are busy. Further, we can often even shape when demand comes in, especially when the referral source is another health professional.
  2. The supply of staff at a M*A*S*H is consistent, they live there! Not so in health care. Staff availability is often based on historical scheduling routines, collective agreements, vacation day coverage rules, training events etc. Available staff fluctuates but often without reference to demand.
  3. M*A*S*H patients are assigned to a priority based on the front line person’s content knowledge. Today in health care, patient priority categories are often created by those with positional power (e.g. ‘only needs wheel chair assessment’ , ‘ hospital ALC patient’, ‘post-hip replacement’, ‘lives in a long term care home’).

Over and over we hear “we need to prioritize because we have more people than we can serve with the resources we have.” Hard to argue with that when your are in a perpetual crisis.

One CEO recently told me “I feel like we are trying to dig ourselves out of a hole”.

The good news is that many health care organizations are trying to understand their patient demand differently. In addition to understanding the severity of patient issues, they are working to stream the patient to he right sequence of care. Typically, creating a few standard admission streams will cover more than 90% of the patients presenting in most scenarios we’ve studied. What defines each stream is a unique organization of clinicians, tools, and know-how to effectively and efficiently deliver what is needed.

The quality improvement and engineering disciplines have much to offer health care in this area. Wait times for service drop when:

1) a full knowledge exchange with the patient is followed by

2) streaming to the right set of standard work procedures that are

3) available to meet demand.

The goal is to do today’s work today, not prioritize, wait and re-prioritize tomorrow. This is what happens when we classify according to severity alone.

Just like the storied M*A*S*H 4077, health care agencies need strong interpersonal relationships, good humour, and innovation to be effective within these environments. With this, and a healthy dose of quality improvement discipline, we are writing a new story line for how health care access works in Ontario.

2 thoughts on “Triaging in health care. Time for new thinking….

  1. Anonymous

    The last episode of M*A*S*H* was in 1983.

    Also, much of what you do is actually the lean philosophy. Might as well call it that so people won't be wondering…

  2. Jeff Doleweerd

    Thanks for the correction on the MASH epidosde timing. Made the fix.
    You are correct. Some of what we do has great similarities to the quality improvement ideas becoming popularized as 'Lean'. There is still a lot of misunderstanding about what 'Lean' means to a health care audience, so saying it doesn't always add a lot of clarity… We also like to tap into other disciplines and schools of thought, such as systems design and six sigma, to get the most relevant ideas that can drive improvement in health care.
    Thanks for the comment.

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