By Marianne Jackson.
Both regulations and traditions dictate that hospitals have a large number of standing committees to oversee a wide variety of subjects. These include patient safety, pharmacy and therapeutics, nursing practice, medical executive council, medical forms, and dozens of others. Each tends to meet monthly or quarterly to manage the business forwarded to it from other committees.
Problem solving in this manner, not surprisingly, can take 10-12 months, as agenda items go back and forth for comment and revision before passage. This pace and chain of command is unacceptably slow for the responsiveness required to meet Lean goals of rapid cycle improvement.
In a Kaizen event held to improve patient flow through a chemotherapy unit, nurses identify a source of significant delay. A patient whose central IV access port is occluded needs Altepase®, a thrombolytic agent to restore patency for laboratory draws and administration of fluids. This requires an order by the patient’s physician, though the dose, means of administration and procedure have been covered in a previously accepted, detailed protocol. Having to call for the order for the agent often delays lab results and patient care by 45 minutes, causing physician interruptions and wasted capability of the nurses. Using the previously accepted hospital procedural protocols, the Kaizen group develops standing orders for the use of Altepase® in the case of occluded lines.
The “business as usual” route for acceptance and implementation first requires approval by the oncology attending physician staff at their monthly meeting. Approval is unanimous. Next month, it is taken up by Nursing Council for review and comment. The following month it is sent to a sub-committee of the Pharmacy and Therapeutics Committee where a wording question sends it back to the Nursing Council for their next meeting. Once clarified, it returns to the sub-committee of the Pharmacy and Therapeutics who send it on next month to the full Pharmacy and Therapeutics group who send it on to the Medical Executive Council where questions that have been addressed at the original Nursing Council meeting arise again without sufficient representation to answer them directly. Once more it returns to the Medical Executive Council but fails to make it to the monthly agenda because of more pressing problems. It is now 10 months from the Kaizen event, and this less than 150 word proposal still has not passed. In the meantime, delays and frustrations remain, physicians become angry at the calls for what they thought had already been approved, and extensive time is required by the Lean facilitator or Team Leader to keep pushing this small item through the labyrinth of committees.
The example could have been taken for requests for IT changes to physician order forms, creation of new OR policy, changing scheduling templates for clinics, implementing new clinical pathways or redesigning internal facility environments for better flow and a host of other improvements.
While patient safety is paramount in the considerations of instituting new protocols for patient care, the procedural review process used by hospitals in their business as usual model is cumbersome, wasteful and unresponsive. The effect on improvement teams is to dampen their enthusiasm for participating in what feels like fruitless improvement work and reinforces their expectation that nothing ever gets done. Kaizen team members see their improvement ideas as too small to matter to those higher up the leadership ladder. Additionally, the various committees are encumbered by a plethora of small agenda items that should be managed at a more agile level.
The charge for hospital leadership is to design faster multidisciplinary tracks for review and approval of items generated from Kaizen events and other improvement efforts that cross multiple departments within the hospital. Some hospitals have developed Patient Safety Alert teams that perform rapid analysis of inadvertent medical mishaps and institute safeguards with tight deadlines.
Similarly, I propose that Lean hospitals must have operations teams with representatives willing and able to take initiatives that have hospital-wide implications and shepherd them through approval procedures using electronic conferences, email, and other tactical means with expectations for approval and implementation or denial within a month. To be any less responsive diminishes the energy and motivation and the effectiveness of the Lean process. Rapid cycle, continuous improvement by frontline staff will feed itself with greater gains when leadership functions with urgency and develops a model of “business as imperative.”