Lean Transformations Group

Patients First (Part I)

Somewhere, out in the highways and byways beyond all the political wrangling and handwringing about health care, there is a steady stream of real people with real maladies who are entering emergency departments hoping to see a doctor for help. Night and day they come, literally by the thousands. Some leave without ever being seen. Some languish for hours in a hallway bed awaiting care. Some die while they wait.

This is heartbreaking, and completely fixable. It's not easy, but it is doable. I've done it twice and I've seen the impact that investing a few hours and really studying every aspect of healthcare delivery can have on patient care, costs, efficiency, and overall satisfaction.

When I arrived at the Mayo Clinic in Rochester in 2000, I was focused on education and research. In year three, I was asked to chair the Quality Committee of the Emergency Department. It was a Mayo Clinic requirement that every committee have a physician leader. By the second meeting (maybe even halfway through the first meeting) I realized that I was not familiar with the language being used: It was engineering and practice terms that I was wholly unfamiliar with. Typically, clinicians will seek more rooms and more staff. Our main issue was to make better use of the facilities we already had, and figure out how to cut wait times for patients and increase efficiency in every way possible with our current resources.

I sought out and found a Quality mentor on the Mayo staff, and they helped me begin to grasp the taxonomy and the scope of the task ahead of us. I studied process improvement and cultural change. I had a great team, and we began to eliminate redundancy and wait time. We reduced unnecessary steps in the process and soon began to experience amazing results. Over time, we continued to improve, and the patients were the beneficiaries.

But soon, our improvement leveled off, and we started thinking about what else we could do. One day, one of our staff said "You know, other industries have figured out how to take every step out of the process that doesn't add value. Why can't we do that?" We reached outside of the Mayo Clinic for help and found a new partner, this time a Lean consultant who helped us begin to understand the value streams, and the process itself. Over the next two years, we learned to create flow in our emergency department, our staff was engaged and happier, and there was no hallway care at all.

All of this happened because the Mayo Clinic understood that adding more staff and more rooms was not the solution to their problem. You have to eliminate waste before you decide to invest in more people and more space, or you only expand the systemic inefficiency problem to a bigger canvas.

It took a while, but after a couple of years on the Quality Committee it occurred to me: In health care, doctors are trained to detect disease and fix it; nurses are trained to deliver health care, to give medication, take vital signs, assist the patient with their personal needs, and so on; administrators are trained to manage human resources and to strategically deploy capital.

But nobody in health care is trained to reduce waste and perfect processes. Interestingly, clinicians do something like continuous improvement in other areas that we work in, especially research into the things that are killing us. That's why the mortality rates are better these days than they were 30 years ago, and cures for diseases and new discoveries are being found. But, the gift for making the system itself more efficient for the patient is not a part of what doctors do every day, nor is it anywhere in the training we receive, and frankly, it should be.

On to Texas

After leaving Mayo, I became the medical director at Trinity Mother Francis Hospital in Tyler, Texas, a sprawling, very busy emergency department with 14 overworked emergency doctors and 64,000 annual patients (in a facility where 52,000 was capacity). What I learned very quickly when we started the process improvement was that this was already a tremendous team of people who were doing amazing work but knew they could do more and be much more efficient. On Friday and Saturday nights, the hallways would fill up with beds because the emergency room was doing its usual land office business, and our systems were, if not broken, at least cracked and in need of a fundamental change.

Here's what happened. We replicated what we did at Mayo, and even though the number of patients we see has grown, we have become more efficient at delivering care to each and every one of them without adding any physical space.

How did we do this? Well, first of all we reminded ourselves that the patient is the focus of our work. Anything that doesn't add value to the patient experience was dropped or changed so that it would add value. As doctors, we had to realize that the process was not about us, and we had to subjugate what we thought worked best for us to what worked best for the patient. Period.

The good news? This can be replicated at any hospital at any time in any part of the country. It will require a paradigm shift, and it will mean that doctors will have to spend some time in meetings and heading up committees that need their contributions. But, I've been there and I can tell you that the short-term investment is worth it. I got into the health care field to save lives, and the last thing I planned on doing was to chair a committee and study process improvement. In the beginning, I asked myself how all of that ancillary activity could have anything to do with my mission and calling.

But I've seen the answer to that question firsthand, and I continue to see it each and every day. The bottom line is this for those of us in the health care field: The process should be designed for one thing and one thing only – to serve the patient. And, when you actually do that, the results are stunning.

Dr. Luis Haro is Medical Director at Trinity Mother Frances Hospital in Tyler, Texas

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