“Patient Centered Care” that leads to Resistance to Lean Efforts

By Marianne Jackson

The Institute of Medicine (IOM) adopted Patient Centered care as one of its 6 major aims for quality, along with Safe, Effective, Timely, Efficient and Equitable.  As defined by the IOM, this means “providing care that is respectful of and responsive to individual preferences, needs and values and ensuring that patient values guide all clinical decisions.”   Another way of saying this is that patient centered care provides patients both choice and voice. By choice, it means providing patients with information about the consequences of their decisions and behaviors and by voice, it means allowing them to make the final decisions.

In actuality, well-meaning caregivers on occasion substitute their own notion of what patients need or want under the guise of “patient centeredness.”   The result may be unintended quality problems.  The following are three cases observed by me during the last year:

Case #1 – Non-standard work

A walker-dependent patient needed urgent laboratory work that required a long trip to the clinical lab.  Believing she was doing the patient a favor, the nurse offered to draw the labs in the clinic.  In the process of entering the lab requisition, she was interrupted and asked another nurse to finish printing the labels.  Returning, the first nurse drew the sample but was interrupted again and asked a third nurse to finish packaging and sending the sample. Unknowingly, the wrong labels had been printed from an open computer and the specimen was sent under another patient’s name.

The clinical lab has standard procedures and dedicated staff to enter requisitions, print labels, and draw specimens.  Straying from standard practice to do a patient (or another nurse) a favor, or trying to provide “special” care led to a major quality error.

Case #2 – Push vs. Pull

Patients often wait more than 30-45 minutes to be seated in this chemotherapy clinic.  Aware that the hospital places patient satisfaction as the highest priority, clinic managers push to move patients from the lobby to infusion chairs whether or not the infusion nurse is ready to provide services or whether the patient’s necessary lab results and chemotherapy orders have arrived.  Other patients arrive who are ready to be served but the chairs are now full.  Both sets of patients are actually waiting, some in chairs and others in the lobby due to a misguided effort to prevent patient dissatisfaction.

In a “pull” system, the downstream nurse signals a need or availability to take a patient as opposed to a “push” system in which patients are moved but no services can be given.  In this pull system, chair nurses would call for patients when they are ready to provide care and the chairs would be fully utilized.

Case #3 – Value vs. Non value waiting

Patients having chemotherapy infusions often see their physicians prior to the infusion with an appointment on the same day to discuss their progress, review their labs and have chemotherapy adjustments made.  The time required to draw and process labs is 60 minutes.  Aware of frequent patient complaints about clinic waiting times, schedulers resist making laboratory appointments 60 minutes prior to the MD visit because they see it as wasted time for the patient rather than as a valuable component of the visit.  As a result, patients are seeing their physician without results, which also subsequently delays chemotherapy orders and infusions.

These behaviors occurred in departments that have embraced Lean principles to address patient flow and satisfaction issues.   Despite Lean training, value stream mapping, kaizens and work with a dedicated Lean coach, the effectiveness of the efforts has been limited by the cultural resistance arising from employee’s judgments about  “patient-centered care.”

Many nurses and clerical staff take pride and are rewarded for rule bending and “going the extra mile” for patients even when this behavior takes the form of non-standard work and may not reflect the patient’s choice or voice.  It can also lead to unintended quality consequences.

Successful implementation of Lean in clinical environments is challenged to:

  1. Engage the voice of the patient whenever possible.
    1. Bring experienced patients to be members of Kaizen events.  Use their voice to develop problem statements, value stream maps and countermeasures.
  2. Identify the staff assumptions about what is patient-centered as opposed to truly value and non-value added services.
    1. Use focus groups of patients with staff to challenge these assumptions.
    2. Use root cause analysis of errors to identify non-standard “helping” efforts that led to quality problems.
  3. Monitor Lean improvements for patient response and incorporate their actual experiences into the PDCA cycles of changes.
    1. Survey patients after improvement efforts to uncover consequences of the changes.
    2. Keep experienced patients as on-going members of the team after the Kaizen event
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