Tuesday, September 2, 2008

One Bad Apple

Some bloodwork needs to be done urgently. The system has been reviewed by consultants, the lab has been optimized for six sigma, the nurses have arranged for standing orders yet one bad apple can screw things up. Check out the story at Emergiblog how one dick of a doc arranged with a clerk not to put through any orders without his express approval. With one word, an entire system is ground to a halt.

Even though it seems like an isolated incident, off-the-cuff instructions like this wreak havoc in clinics. The front desk is beholden to their managers, the nurses, the doctors as well as any other people that have a vested interest in how many patients arrive at once. It is not uncommon for a nurse to approach the front desk and give 'guidance' on how to fill the day or a doctor to 'forbid' one front desk staff to book a type of patient during a certain time. With 10 providers, 20 nurses and 15 front desk staff the problem is obvious.

How do we deal with the problem? We've given strict instructions to the front desk administrators to change the scheduling template only when instructed by the administrative supervisor. When approached by a nurse, doctor, assistant, whoever to change things they simply say, "You'll have to talk to XXX, I'm not allowed to change that".

It is more complicated when one of the doctors that's a part owner of the clinic says it (telling your boss you cannot change something can be a career altering event in any job) so the front desk has separate instructions for this situation. They are instructed to do as the doctor says then report the change to the administrative supervisor who, in turn, sends out an email to all of the doctors to find out if the change is global. When one of the doctors has made a short-sighted decision he/she has to answer to peers rather than the front desk staff.

Service industries are not a factory floor. Variation is more difficult to control. Quick decisions are necessary so it is counter-productive to make an environment where the employees have no control over the schedule. Rather than shutting the system off to input from the people that are affected by it we've built the system to accommodate for changes through a central contract person. Even though Emergiblog was the one affected by the 'dick of a doc' it may be that he/she had no other option. In the end, creating an environment where change is impossible can be create far more variation than allowing independent thought and action.

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