Friday, May 2, 2008

5 Whys

How do you get to the bottom of scheduling problem? Toyota suggests asking why 5 times to find the root cause. Here’s a true example.

The other day I came out of a consult and saw that the patient had been booked an hour previously (it was 3pm and the patient was booked at 2pm). We try to get consults in and out within 50min of their appointment time so I went to ask the administrative and nursing staff what happened.

Why 1: Why did I keep the patient waiting so long?
Answer: You we’re late going in to see her.

Why 2: Why was I late going in?
Answer: Because you went in to the consult with the patient that was booked after her first and her appointment was for ½ hour.

Why 3: Why did I go into the patient that was booked second?
Answer: Because we finished her medical history first and there was only one room available

Why 4: Why did we put her in the room first?
Answer: Because both patients arrived at the same time

Why 5: Why did they arrive at the same time?
Answer: Because we confirm patients on the ½ hour. So if three people are booked between 2pm and 2:30pm (consult at 2pm, consult and post-op and 2:15) they are all told to arrive at 2:00.

So the solution was two fold. First, I now carry a day sheet so that staff doesn’t have to worry about directing me into the next scheduled room. Second, post-ops are asked to arrive at the time of their scheduled appointments and consultations asked to arrive 10min prior to allow for registration. This avoids the “wave” of patients that increases variation. Interestingly, there’s more variation in the amount of time people wait in the smaller offices but fewer patients go over 50minutes. My assumption is that the lack of rooms, prevents us from leaving someone for too long a period.
When surveying our staff every group (doctors, nurses, assistants, administrative) all list “organizing patient flow” near or at the top of their perceived responsibility list. As this example illustrates, the root cause of running late was not as simple as “you took to long with the first patient”. Good patient flow, comes from good scheduling technology and good teamwork.

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