Thursday, March 24, 2011

Standard Work for ER Residents

As a non-clinical member of a large hospital, when I can get even 30 seconds with an ER physician, I consider myself lucky.  Today, I got about 5 minutes with one, which gave me the opportunity to throw some ideas out there about ways to standardize and kaizen repetitive aspects of his job.

The Concept

I mention 'standardize' and 'kaizen' together, because as Taiichi Ohno said, "Where there is no standard, there can be no kaizen."  Standard work gives us a baseline from which we can analyze deviations, which leads to the discovery of problems, which through good problem-solving leads to continuous improvement.  Without the baseline, we can't even tell if we have a deviation.  That's why I was discussing standardization with the ER physician today.

The Specifics

We specifically discussed standard work in the context of the Resident-to-Attending report-out.  This is the process by which a Resident (a med school graduate who is in-training) reports to the Attending (a senior physician) on the condition of a patient and what the treatment plan should be.  This is typically done verbally, which makes it critical that there be some sort of structure around the verbal report-out.

In med school, students are taught reporting structures such as SOAP that help provide some standardization to the report-out process.  If we say that the SOAP approach is our standard, we can at least check to see if it is being used and look for deviations.  If there are deviations, we can ask why and keep asking why until we get at the root cause.  If needed, we can find a better standard.  The point is, we need something to get us a baseline from which we can assess the process.

The Reason

But why do we even need to worry about the Resident-to-Attending report-out process?  Because it causes patient delays, which can cause patient safety and quality of care issues.  Until the Resident reports to the Attending and a plan of care is agreed-upon, you don't usually see any orders being placed.  No orders, no treatment.  Nurses can do their best to monitor and support sick patients, but until orders are placed it's hard to provide much care.  That's why we need the best Resident-to-Attending report-out process possible, which is why we need standard work and good problem-solving.

Of course, this whole problem makes me think, is there a better way?  Is there a different model that would allow Residents to get the training and monitoring they need from the Attending without creating delays for patients?  That's true north for the Resident/Attending relationship.