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Triaging in health care. Time for new thinking….

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.

Can We Make Health Care "Googley"

Much has been said about how we, in health care, can learn from companies in other industries such as Toyota (Lean), or maybe even about how hospitals (especially ORs) are like airports.

The stories about these industries have been around for years. So lets see if we can take a page from the success story that is Google and see what can be applied to health care.
Take a look at Google’s design principles (i.e., what makes them “Googley”). According to Google:

“The Google User Experience team aims to create designs that are useful, fast, simple, engaging, innovative, universal, profitable, beautiful, trustworthy, and personable. Achieving a harmonious balance of these ten principles is a constant challenge. A product that gets the balance right is “Googley” – and will satisfy and delight people all over the world.”

Design Principles:
1. Focus on people—their lives, their work, their dreams.
2. Every millisecond counts.
3. Simplicity is powerful.
4. Engage beginners and attract experts.
5. Dare to innovate.
6. Design for the world.
7. Plan for today’s and tomorrow’s business.
8. Delight the eye without distracting the mind.
9. Be worthy of people’s trust.
10. Add a human touch.

Of these 10 “design principles”, which were created with web software in mind, at least 6 (highlighted in green) of them can be applied to health care, health care process design, and health care software design.

#1. “Focus on people – their lives, their work and their dreams”. This is coming from a software company! This line perfectly suits health care as well. No explanation required – particularly for those working in areas of community care where care must be personal to be good.

#2. “Every millisecond counts”. While every “millisecond” might be a bit extreme for healthcare processes, certainly every second counts. Consider this: for an average sized CCAC, when the administrative burden of processing information required to bring a client onto service is reduced by just 7 minutes, it is like having one more staff on board to care for patients.

#3. “Simplicity is powerful” is extremently important in process design, both for the client and the health care worker. One of the biggest offenders of this principle comes in forms design. Over and over again we find forms that are asking the wrong questions, asking for too much information, or asking for it in a confusing way. This is a hassle at best, and can compromise safety, at worst. A good form or software interface is a work of art – simple, intuitive and requires no training. How many hours of classroom training did you need to use Google?

#8. “Delight the eye without distracting the mind”. This principle applies directly to Health care IT systems specifically, as opposed to the industry as a whole. Health care IT systems are, with a few exceptions, a) unnecesarily complex b) difficult to use c) ugly.

#9. “Be worthy of people’s trust”. As clients become more “consumer” oriented, health care providers will more and more need to prove that they are trustworthy. Is the “system” designed in such a way that clients can “trust” that it will work?

#10. “Add a human touch”. This one speaks for itself. What front line staff did not get into health care to help people? The challenge is for organizations to enable their staff do this. This is more than customer service. This is listening, understanding, taking time to be effectively present to people who need care. This also means knowing who your key client groups are, and understanding what is important to them. Ensuring their voice travels from their living room to the health care organizational board room.(More about this later)

And, let’s consider this from a slightly different angle … can health care organizations interact with the public using a “human touch” (or would that be … gasp … “unprofessional”).

Consider the following line from the “Official Google Blog” discussing the design principles:

“Still, we don’t want to waffle too much. These principles represent the User Experience group’s declaration of beliefs. With “Satisfy and Delight” stitched on our leotards, we’re determined to get up on the tightrope and start juggling principles. Please applaud or boo, as appropriate, so that we can make the next act even better.”

When’s the last time you saw a health care organization have a press release that said anything like “with ‘Satisfy and Delight’ stitched on our leotards”? Would they get your attention if they did? (It would get my attention, that’s for sure).
Is it too far a stretch to make health care a little more Googley- to both satisfy and delight? We think not, and suspect that the health care leaders of tomorrow feel the same way.

Forms Waste: The Story of Kung Fu Panda

One Friday evening, I asked my kids the usual, ‘What did you learn at school today?’ Excitedly, they said ‘our whole school went to the gym and watched Kung Fu Panda’. My one daughter volunteered that ‘the teachers needed time to get their report cards filled out’.

We have an awesome school with very dedicated teachers and one of the best principals I have ever experienced. There have been huge changes in the past few years, systematic improvements, particularly in the reading program. I tucked my kids story in the back of my mind for future inquiry. Why would a school with such commitment to learning be sending the kids to watch movies when they also report having so little time to get through the curriculum? My spidey-senses were tingling (ok, wrong super hero).

Speaking to teachers and others behind the scenes shows the cause… A new report card web-based tool was deployed to hundreds of teachers across the school board. This software had a noble beginning. It was to replace the current electronic process with a more centralized method of making reports cards shareable across teachers and sites. The result included something else. It was a tool that even technically savvy teachers struggled with over many hours on their own time, spanning weeks. As desperation set in and deadlines approached, classroom time was redirected to completing the report cards.

So what was a typical problem with the tool? The reporting form only permitted 250 characters in the space provided for a comment. Clearly not enough for many scenarios. Worse yet, the teacher would only be triggered to going over the limit when they tried to save the form. Time was then spent locating the offending comment field by counting each field’s characters, and then rewriting the comments to fit in to the magic 250. The really keen teachers identified that ‘w’s counted as two characters. Staff were losing the battle.

The result was a a principal forced to re-deploy an excellent group of teachers away from spending time with kids to form filling. The bottom line was Kung Fu Panda, not curriculum, and a report card that incidentally had even less information on it for parents than the previous one.

This is a storyline all too familiar to health care workers. New assessment tools, admission forms, status reports, activity tracking forms and applications that involve lengthy handling times when they are rolled out to the front line, and poorly tested in a real care scenarios. There are only so many nurses, case managers, physicians and therapists so the result is inevitable. Less care for people who need care. A simple, well designed, intelligent assessment form, devoid of repetitive gathering, only containing information people really use, is all too uncommon.

So what might high performing community care organizations be doing? Firstly, they are redrawing the old battle lines. They are engaging in a process-oriented discussion with their partners and starting a superhero-like battle against pure waste across departmental and organizational boundaries. With limited resources, leadership is driving a culture that sees over-processing of information and useless travel, for example, as the new enemies. Conversely, they are agreeing on what value really means to clients, regionally, by asking them directly and setting about to improve results across the whole process spanning several agencies. With laser beam precision they are using their collective powers to remove activities, policies and procedures that get in the way of care. High performing managers are recognizing that even small process changes to high volume processes have a massive impact on the client experience, with staff feeling more valued because they are delivering value.

Those not doing this might start asking their aging patients which movie they would like to watch while they wait for care to arrive… Gone With The Wind may be appropriate.

Kaizen vs. Control

There is much enthusiasm these days about Kaizen in Health Care (and rightfully so, it’s a great philosophy). It is a Japanese term meaning:

‘Change for the better’ or ‘improvement’. A business philosophy of continuous cost reduction, reducing quality problems, and delivery time reduction through rapid, team-based improvement activity.

However, it is often pursued without due attention to it’s prequel, “Control”:

“the activity of ensuring conformance to the requirements and taking corrective action when necessary to correct problems and maintain stable performance”
(Evans, Lindsay, Management and Control of Quality 6th ed)

Control is necessary for effective daily management of processes and involves process goals, measurement and evaluation. Without control, it is premature to talk meaningfully about improvement (or “Kaizen“).

For example, let’s say that a Community Care Access Centre wishes to run a Kaizen Event to improve the timeliness for new client assessments. First ask the following questions:

  • What is the “target” level of timeliness?
  • What is the “current” level of timeliness?
  • How close are we?

If these questions cannot be answered, then there is no basis for effective daily management and it is time for a control rather than kaizen improvement exercises.

Do you ever hear leaders in health care speak about the number of kaizen or other improvement events they held last month or last year? Be careful. This isn’t a measure of mission impact nor of organizational performance. First seek to control, then improve, because you can’t improve a process out of control.

"Human Vigilance" as the backbone to our system?

Many business processes in health care come about by evolution, rather than design. Problems are often patched, rather than fixed. Many procedures are very labour intensive, rather than automated.

When a process is evolutionary, patched and labour intensive, it’s success ultimately depends on the vigilance of the people in the process. Consider the following examples:

A nurse writes down an order for supplies and hands it to a clerk, who types the order into the supplier order system. A clerk from the supplier then prints out the order and hands it to Joe the supply picker. Joe reads the order for “30 cases of gauze” and since he has been a picker for 8 years, Joe knows that the nurse meant “30 boxes”, and changes the order. When 30 boxes arrive at the hospital, the nurse never even knew that something when wrong.

Now, if Joe had only been a picker for 1 month, the nurse would have received 30 cases, and had to send most of them back. But, the process worked, and nobody was worse for wear.

The challenge is, we rely on people like Joe everywhere in health care. Often it works, but sometimes it doesn’t. Most drug errors can be attributed to handwriting errors, and we rely on Joe to catch it. In fact, the institute of medicine reported that transcription errors are so prevalent that a patient can expect to be subject to a medication error for every day that they are in the hospital.

Modern Manufacturers build fail-safes into every part of their system. Go work at Toyota and just try to lose a finger, you won’t be able to do it. The machine will turn off, or a supervisor will stop you or some other intervention will occur. This is because they designed the requirement for human vigilance out of the system.

The health care industry has seen some success primarily in the area of devices, such as safe sharps.

Though not a safety issue, the opportunity to design “out” the change to make mistakes exists for business processes as well, such as documenting assessments, referral handling and supplies ordering.

The solutions might take the form of technology, process changes, or even something as simple as redesigning the usability of a form.

When redesigning a process, look for the opportunities for error, and make the error impossible to perform. Engineering tools such as Fault Tree Analysis are excellent ways to shed light on the problem