Managing Complex Change Diagram

I came across a useful diagram at work the other day while working on a big project at the largest hospital in our system.  While working there we were up against a staff that was very change averse.  An organizational psychologist was recommended by the administration team to talk with us regarding the hospitals work culture and we were given this diagram below to help us determine what our project was missing to get it on the right track.

The diagram shows high level pieces that need to be addressed in order to successfully help the person accept change.  Following the flow diagram from left to right, change will not happen as desired if any piece is missing.  The person going through change will then experience the far right outcome depending on the missing piece.

Right Care - Right Patient, Not Just About Improved Clinical Outcomes

Nearly everyone in the field of health care by now has read or seen a reference of the report "To Err is Human", which in 1999 brought to light the high amount of medical errors that lead to death in this country.  Stemming from that was an onslaught of quality improvement initiatives, root cause analyses, and overall shift in how we as a society went about providing health care.  That study is probably the main reason the four of us blog contributors got to where we are today, trying to continue improving our health care system from as many facets as possible.

Providing the right care to the right patient, which seems simple enough at a high level, was not being followed on a patient level and it was costing United States health care facilities millions in malpractice suits and worse costing lives. Over a decade later, right care to the right patient is still something health care facilities may struggle with or even worse may not even realize an error is happening.  My first official project as an Operations Improvement Specialist was at a small town hospital in southern Wisconsin that was experiencing decreasing patient volumes and was struggling to meet the budget set last fall.  Having only one inpatient unit spread on two floors, with roughly 30 inpatient beds total, improvement options from the outset appeared minimal.  The goal of the project was to cut cost of operations in any way possible in order to secure the viability of the hospital in the future.

Patient satisfaction and clinical outcomes were never an issue at this location, but they were important to the project in that any recommendations made would need to ensure those high marks still were met.  However, being in a rural area, patient volumes were a real problem and a cause of poor labor efficiency.  To help minimize the effects of high staffing, patients were in many cases allowed to be roomed on the intensive care unit to give them the patient volume they needed.  After examining the acuity of these patients that were housed on the ICU, it was very apparent this was a case of over treatment, and it was costing the hospital double what was needed in wages alone.  Couple the wage discrepancy with nurse to patient ratios being much higher in the ICU and the total cost was nearly $250,000 to the organization.  The care being given in this case was not worse in terms of nursing care, but from an operations standpoint the cost to provide this service outweighed the benefits.

Since our look at the hospital, a move has been made to absorb the excess capacity that was treated in the ICU on the med/surg floor.  In order to accomplish this other initiatives were needed to reduce their patient volumes such as discharging patients earlier in the day and holding their observation patients in a different location.  Work is being done to better understand the data through our electronic medical record and provide weekly data updates to track progress on discharging earlier and better patient assignments.  The goal is by budgeting process of 2013 to accurately forecast volumes with changes in place.

To Err is Human

Case Against Benchmarking an Organization Nationally

A major part of the work being done, for the health care system I work in, to improve operationally relies heavily on benchmarking.  I am not going to try and explain the detailed process but it definitely consumes a lot of the time I spend at work in some fashion.  Dating back a decade or so, the organization decided that in order to compete with other hospitals across the country it would be necessary to compare operating statistics, focusing primarily on productivity.  The goal was simple enough:  improve your productivity numbers and your costs would decrease.  Productivity in this case referred to worked hours per unit of service, which was a ratio that determined in essence the amount of work that was paid for to complete a volume of service that represented roughly 80% of the value added work they did. For example on nursing units the service is patient days.

This system has been in place for at least a better part of the last decade and has evolved over time to accommodate more departments and different services.  However, as health care is changing at an ever rapid pace, is benchmarking to a national database the best way to continually improve an organization to keep up with the changing landscape?  I will go on record as to say it is not the best practice and improvements can be made without comparing nationally.  There are several issues that I would like to address.

Issue Number 1.  Substantial Time Involved in Creating Benchmarks.
  -  Without going into details into what benchmarking entails where I work, it involves substantial man hours to update and maintain the benchmarks.  It at a high level requires obtaining data, submitting it, finding the appropriate compare groups in the database, and then setting targets for hundreds of hospital departments.  The targets are then used to drive improvement, however the sheer volume of time for the task of creating and maintaining these benchmarks puts limits on the time that can be spent actually improving a department.