Shock Absorbers in an ER

In an Emergency Room, it's pretty hard to control the volume and acuity of patients coming in the door.  Variation is inevitable.  It's like riding down an old dirt road--you have some smooth spots and some bumpy spots.  That's why our cars come with shock absorbers.

What is our shock absorber in an ER?

How do we mitigate the effect of variation in patient volume and acuity?  Sometimes, we take the wasteful but safe approach of over-staffing.  Or, we might look at the measures of central tendency and variability in our patient volumes and acuity, and come up with a staffing model that is both statistically reliable and much less wasteful than blunt force over-staffing.

Being able to absorb the shock of uncontrollable patient volumes and acuities is especially critical if an ER is attempting to go to a cellular flow model.  In this model, you might try to even out the variation by distributing patients to the multiple cells evenly.  This works well as long as the cells are equipped for all patient types.

If, however, a certain type of patient can only be seen in a certain cell, and a bunch of those patients come in at the same time, then we have a big problem.  In this circumstance, we need a different kind of shock absorber, perhaps flex resources (doctors, nurses, etc.) that are not assigned to a single cell, but that can flow to where they're needed.  Of course, in the long-term, we should try to even out the capabilities of the cells so that this whole issue is moot.

Whether it's through blunt force over-staffing, statistically sound staffing, level loading to cells, flowing flex resources to unleveled cells, or evening out of cell capabilities, we absolutely must have a way to ride over the bumpy spots in the road.  We have to have a shock absorber.

When the Gemba is an ER

As any student of Toyota knows, going to the gemba is step one when investigating a problem.  This principle is often referred to as genchi genbutsu, and lean thinkers know why it's such a powerful and almost mandatory concept.

But what about when the gemba is an Emergency Room?

My first thought is that all workplaces are different, but what we're looking for pretty much stays the same.  In other words, a gemba is a gemba.  But, having spent enough time in ER's recently, I think there are a few differentiators that we can take into account:

1. The doctors are the touch labor.  Whereas in manufacturing, we sometimes see the problem of the touch labor employees not being respected and their voices not being heard, we sometimes have the opposite problem in healthcare.  Doctors are so well-respected, and sometimes so feared, that they can have an almost unwieldy amount of influence.
2. Everybody is at a computer.  No, they're not playing solitaire or checking Facebook.  They're working extremely hard to enter their patient encounter information into the system.  In modern healthcare, it feels like everything is dependent upon electronic information management.
3. Flow is hard to see.  Many ER's were not designed with one-piece flow in mind.  Or cellular flow.  Or pull systems.  Or level loading.  Or visual management.  Or any of the other concepts that help improve flow and make flow visible.  The structural design of many ER's can make it almost impossible to see the flow of patients through the system.

If you're a lean thinker looking to make the move to healthcare, these are just a couple of thoughts to keep in mind.  But, if you're a lean thinker, you've probably been to many gembas and you probably know that each one has their own set of differentiators.  An ER is still a gemba, just one that maybe requires a little extra patience and finesse.

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.