Team shadowing patients finds inefficiences, wastes
Gary Linger's first-ever hospital stay came at age 70 when he was admitted to Providence Regional Medical Center's Everett, Wash., campus for cardiac bypass surgery. He admits he was afraid.
"When somebody tells you they're going to open you up and do things to your heart, well, it got my attention," Linger recalls. But, he added, "the fear of the unknown is always the worst," and both he and his family drew comfort from the extensive communication and education offered throughout his stay in the cardiac unit at Providence Everett. This included detailed discussions of the "what, how and why" of everything that happened to him leading up to the surgery, he said, with numerous opportunities for questions.
After his surgery, he paid close attention to a bulletin board in his room. The board identified his caregivers as well as every diagnostic or rehabilitative procedure that was planned for the day and the goals he would need to meet if he wanted to go home on schedule.
"As a patient you can get confused about all these things, but they had this bulletin board right across from you so you could see it all laid out there," said Linger. Today that bulletin board — once unique to the cardiac unit — is a dry erase whiteboard and is ubiquitous at Providence Everett, partly because of Linger's participation as a patient-and-family representative" in an innovative collaborative care partnership between the hospital and the Everett Clinic, a large multispecialty practice in suburban Seattle.
His positive impression of the cardiac unit was one of the lessons learned during an ongoing effort to "rebuild the hospital journey" and address issues of accountability, fragmentation, communication breakdowns, inconsistent procedures and waste.
Blank slate
The care coordination project began more than three years ago and, like many efforts to improve hospital efficiency, it was brought on by numerous factors — including health care reform and competition with other health systems in the Greater Seattle area. But the most significant driver was the construction of a new $500 million, 240-bed hospital tower that opened in June 2011 and came online without a significant expansion of staff, said Michelle James, senior director of acute care nursing at Providence Health & Services
"We knew this was an opportunity to really transform the way we provide care," James said. "And we needed to ask why we were doing things the way we have always done them. Was there a regulatory reason? A safety reason?"
Using efficiency strategies adapted from the manufacturing industry such as Lean Six Sigma, the hospital and the Everett Clinic formed a team of doctors, nurses, and other caregivers, along with the patient and family representatives. The team followed patients from the physician's office through hospitalization and discharge, logging more than 150 hours of observations from 140 patients and 165 staff.
One of the most dramatic conclusions of the team was that 80 percent of the activity in the hospital could be considered "waste," defined as "anything that a patient would not reasonably be willing to pay for," said Linda Severs, the hospital's efficiency expert.
Examples might include long waits in the emergency department's waiting room, delays caused by doctors walking long distances between clinical units, or — the most common complaint from patients — answering the same questions over and over again.
At first, the "80 percent waste" assessment was met with predictable resistance from the medical staff, said Dr. Joanne Roberts, chief of medicine at Providence Everett and a physician from the Everett Clinic. But eventually, "We all agreed that we were all working in silos, and we were redoing one another's work. And patients were telling us we didn't seem to be talking with one another, which was true."
Saving steps, gaining time
Some skeptics were won over by the realization that greater efficiency in paperwork and other processes could lead to more time spent with patients helping to fulfill the hospital's mission of providing compassionate service.
"If you have to walk down the hall to get supplies, you're spending time walking when you could be spending time doing patient education," said Severs. "If we can take out the waste, we have more time to interact with the patient in a therapeutic sense."
The team proposed a series of changes that affected just about everyone, including the patients, their doctors and nurses, and anyone else on the care team. These changes included:
- Direct admission through a one-call system that allows patients to bypass the emergency department and has reduced the admission process to an average of less than 15 minutes, from 40 minutes or more.
- Decentralized storage of supplies and medications, bringing them into each patient's room at the beginning of the day to reduce travel time by nurses.
- Hospitalists assigned by care unit, as opposed to randomly assigning patients in a variety of clinical units across Everett's sprawling campus. The decision has substantially reduced the amount of time hospitalists spend walking — time that can be spent in patient rooms instead.
- Daily rounding by physician and nurses together, in order to improve communication, save time and resolve one of the most common complaints the team heard: "Why do you ask the same questions over and over again?"
- Daily huddles by the care team, to prioritize care for the patients and identify treatment and diagnostic needs.
This new road map for patient care has not been without some obstacles. For example, Roberts said, assigning hospitalists by unit has sometimes led to badly imbalanced patient care loads for the physicians, an unacceptable outcome that the team is working to correct.
But the results have been notable even before all the recommendations have been fully implemented, Severs said. They include a 1 percent decrease in readmission rates, a 7 percent improvement in patient satisfaction scores and 2.6-hour reduction in average length of stay.
The efforts will continue, she said. "It's all of our jobs to be as efficient as possible and provide the best care as possible," Severs said. "We all have to be vigilant in thinking about why we provide the care in the way that we do."
Copyright © 2012 by the Catholic Health Association
of the United States
For reprint permission, contact Betty Crosby
or call (314) 253-3477.