Saturday, March 22, 2008

Trying to Change Triage

Nurse Dan at Simovative Solutions had a pretty good rant the other day about management trying to decrease ER wait times in triage by bringing patients straight to a room. For those of you not in the medical field, triage is a queuing model where everyone is evaluated (basically first come first serve) for severity of illness by a nurse and usually at the front desk then put into a priority queue based on the severity of their illness. The problem was that management saw a problem, read an article in a magazine (about a smaller rural hospital that tried the solution of straight-to-room triage) then implemented it. Dan wasn’t impressed.

No study, no staff involvement, no goals, just a memo.

This is a typically example of a shot-gun approach to solving a health care wait time problem that rarely works (and if it does you have no idea if it was the change that helped or if it was some other factor). But it’s a great way to introduce the idea of the 4P’s. The 4P’s are from a book called The Toyota Way by Jeff Liker and stand for Philosophy, People, Process and Problem Solving. They are a principle of The Toyota Production system. If Dan’s rant is accurate management missed philosophy and people then took a blind stab at process and problem solving.

It’s management’s job to take a global look at a situation. People in the field are bankrupt of time (especially in a busy ER) and rarely have time for analysis. Dan’s management did the right thing by identifying a problem but it wasn’t framed in quantifiable terms. Rather than: “we want to decrease ER wait times in triage” I think the real goal should have been “we want to decrease the number of people that wait greater than 15 minutes for triage to under XXX / 10,000”. If they choose a six sigma value (a laudable goal) it would equate to 3.4 people per 1,000,000. A more reasonable goal is 3.5 sigma which is 22,700 people per 1,000,000 or 97.7%. In addition, if you use the 5S’s to improve a process, you get a better analysis, plan and employee ownership of the problem.

After setting a goal they could have done an analysis with the people that work triage to identify what they think is causing the problem, come up with a potential solution, implement it, and monitor the “error rate” then change again. This process is called a quality circle.

In my next post I’ll show an example with hard-core numbers about how to develop a process flow map. In a process flow map you diagram patient flow and measure the average time in each step and the amount of variation. As I’ll show in the example it’s usually the amount of variation that is causing the problems with client satisfaction not a subtle change in the average.

1 comment:

NurseDan said...

Great post, can't complain when i am in the first sentence. I agree with you that we needed to do a process flow map to determine where the issue was. I would have to say it lies in the fact that 95% of the cases don't need to be at the ED, and the fact that we order many many un-needed tests! Its the practice of defensive medicine that really bogs things down.

CT's for chronic migraines
CT's for normal labs and non-specific abd pain
CT's for drunk people who slur their words.

Those are the things that need to be cut back on, then wait times can be decreased.

Great Post