The Effect of Too Many Doctor Days

Nothing creates more panic in the eyes of office managers than holes in the schedule. While doctors may complain about too much work and not enough time with a patient, the corollary is a lack of work.

I've watched this scenario play out several times now, and in our own practice it's not uncommon in the October/November period after we take on a new surgeon to have openings. An increase in doctor days (as much as 20% with a new surgeon) and native growth in the practice of 8-10% means space in the day.

The natural tendancy is to try and fill the day. If the day is filled by increasing sevice levels to patients that's great. However, the common approach is to add time to existing appointments.

When a practice accepts a new provider create the following checklist:
1. List appointment types and expected length
2. Use booking templates
3. Review the templates with booking staff then make sure they're followed
4. Allow for more 'urgent' visits. Rather than having a policy of booking days or weeks ahead ask patients if they'd like to come in that afternoon.

The danger of open appointment slots is adding inefficiencies to the schedule by the pressure to fill time. Instead, look at native growth, the change in provider time and have realistic expectations for open time in the first year.

Grand Rounds

Grand Rounds is up with Pallimed. Included is an interview with Tony Clement, Canada's Minister of Health. Not an easy interview to get. Congrads to Sam Soloman.

FreshMD - Welcome to Canada

FreshMD has posted information given to refugees to Canada. It is as moving as it is simply. For instance,

"In Canada, the law lets you practise your religion freely. You will not be asked or forced to change your religion. Freedom of religion is one of Canada’s basic freedoms. There are many Buddhist and Hindu temples, and Christian churches across Canada. In many cities, you can invite Hindu Pandits home for religious ceremonies. "

Well worth the read.

Gallup Employee Engagement Event

Yesterday I went to the “Gallup World Class Employee Engagement Seminar” to learn about best practices for employee engagement. You can read my previous post about the Gallup Q12 for a more detailed description of the tool.

I could wax poetic about how an engaged employee will lead to lower turnover, better business unit performance and more engaged clients. But the entire concept was best summed up by an analyst this way;

“Using the Gallup Q12 doesn’t add to the plate of busy managers it eats the lima beans”

In other words, when an employee is engaged many of the minor problems disappear. Engaged employees look for solutions, stay longer and produce more. They are also prerequisites to sustainable business growth.

The bad news is that in a typical organization, only 30% of the employees are fully engaged and roughly 20% are actively disengaged. The remainder of employees fall somewhere in the middle. Not exactly a recipe for success.

The ratio of engaged : actively disengaged employees is predictive, not only of profit/performance, but also of absenteeism, employee turnover, safety incidents, productivity and client satisfaction.

To quantify it, the average company has a ratio of 1.5 engaged employees for every 1 actively disengaged employee. A world class company has a ratio of 8:1.

When client engagement is optimized the company performs 1.7x better. When employee engagement is optimized the company performs 1.7x better. When both employee and customers are optimally engaged the company performs 2.4x better. In fact if a company is in the top 1% of each the multiplier is closer to 5.4x.

Employee and customer engagement are synergistically related rather than just additive.

The seminar itself was short (3 hours) but informative. Unfortunately, within 15minutes of arriving the hosts asked us how many people we employee. I told them 60 and they said that Gallup only dealt with companies of greater than 1,000. That pretty much ended their interest in our small company as the room (roughly 20 others) was made up of representatives from multi-national organizations. In the end, I got the distinct impression the “course” was more of a sales pitch for Gallup services* and we didn’t fit the mold.

Regardless, yesterday’s event took me well out of my managerial comfort zone and I learned several important perils. Employee satisfaction is not employee engagement and engagement is vital to productivity as well as some techniques to measure and drive engagement.

If your company is over 1,000 you may want to look at Gallup’s services. For the rest of us, the books Human Sigma or The Best of the Gallup Management Journal are good starting points for small organizations. Alternatively, there are some managerial courses provided by Gallup that are approximately $4000 pp.

*Part of Gallup’s value system is to share its’ information with leaders. This course was part of that but you could also hear musing from the staff about “teeing us up” for various services. The Gallup Q12 is also copyrighted and cannot be used without payment. It is a catch-22 since they seem to have no interest in supporting a company our size.

Grand Rounds

Grand Rounds is up today at Notes of an Anesthesioboist.

Check This Out

Happy left a wonderfully glib post to a lawyer who visited his site. You know this one is going to end in a comment battle and possibly a lawsuit. I hope Happy knowswhat he's doing. I can hardly wait to see what happens in the comments section.

New Blog - Life in the Fast Lane

I had a link from a new blog this week. Life in the Fast Lane is the writings of an ED physician from Australia. It is an eclectic mix of comedy, clinical cases and policy musings. 'SandnSurf' is a talented writer and has some skills with the technical side of blogging. My guess is this blog will become popular fast. Take a look at Life in the Fast Lane.

Poka-Yoke: Mistake Proofing an Office

Poka-Yoke is mistake proofing something. Anaesthesia is replete with these handy little tools. For instance the regulator for oxygen will only fit on an oxygen tank due to a pin-index system. On our anaesthesia machines the lowest percent of oxygen you can give is 30% otherwise the machine cuts off and the patient breathes room air.

But PokaYoke extends far beyond life-threatening situations. I’ve previously described how our office had problems managing emails from referring practitioners. At first we just created an email account. We couldn’t tell which emails had been processed into the referral management software (our EMR) so we created subfolders (processed/not processed). Then, the users could accidently drop emails into the wrong folder so there was no net benefit. Finally we created a bit of script that moved emails automatically into the EMR and once the information was entered an automatic email was sent back out with the confirmation information including who had entered the data. Total cost about $3000 and worth every penny.

From a general point of view you want to mistake proof something so that an action is either prevented or met with some sort of control to prevent the mistake. In the case of the oxygen cylinder or referral management there is a forced control of the situation. You can also have an automatic shutdown (as in the case of the low oxygen level), a warning or a sensory alert.

Here are four other poka yoke’s from our office:

Staff Schedule
Our office grew from 20 to 60 staff in short order. Originally we used a plain Excel sheet to schedule staff with an autopublish to the web so they have access to the schedule. Mistakes started to pop up where we would forget to assign a nurse or an assistant to a provider leaving the day short staffed. Using conditional formatting and the countif function we created an Excel sheet that returned visual inputs as a summary function to see at a glance the number of staff per office. Total Cost: $0 as long as you can work Excel

Wait Times Graphs
When we started using wait times as a measure of our success we needed a faster means to visualize our performance. We connected an excel sheet to the EMR for a visual representation of our wait times for critical procedures. Prior to this we would have to count the days, look at the schedule and estimate or go with “a gut feel”. Total Cost $0 as long as you can work Excel

From Wait Time & Delayed Care

Patient Cancelations
When a patient cancels an appointment or forgets to complete a test what happens? Most offices leave the chart of the shelf or call them once and that’s the end of it. Our EMR has a fail-safe that if a patient cancels an appointment they are automatically put back on a recall list. The staff will then contact them again in the usual means. If the patient doesn’t wish to follow through they are removed. Usually, they’ve forgotten the appointment and simply need the reminder. The software prevents us from “forgetting” a patient. Total Cost: Appx $2000 included when we designed the original EMR

From Wait Time & Delayed Care

Confidential Information
Dealing with many young adults our office completes the medical history without parents in the room then we bring them in to hear the information about a surgical procedure (all with the patient’s consent of course). Although the teen/young adult wants their parents present to receive the information about surgery they don’t want them to know a disclosure about marijuana use (the most common scenario). Because we still have paper charts we put a large paperclip over the chart to prevent the practitioner from accidently opening it to the medical history and inadvertently disclosing the information without the child’s consent. Total Cost: 30cents for the paperclip.

Those are just 5 poka-yokes from our office. I’d be interested in hearing what everyone else has done in clinics to mistake proof procedures. For more information on poka yokes at an industrial level (health care) visit http://www.mistakeproofing.com/ or http://www.ahrq.gov/qual/mistakeproof/mistakeproofing.pdf.

Dr. Val's Found a Home

Few medical bloggers have gained greater access or more popular acceptance among the mainstream media than Dr. Valerie Jones. Under the pseudonym 'Dr. Val' and as a member of the National Press Club Dr. Jones gained access to Washington insiders to provide insight into the politics and policies of US Health Care.

Medical Blogging can be a difficult and dangerous business. Most are either amateurs or earn just enough money from ad revenue to pay hosting fees. In general, medical bloggers write to provoke, analyze and share information without a stable of lawyers common to print media. To have someone of Val's stature and talents within the ranks is inspiring.

So it raised more than a few eyebrows last month when Dr. Val's old site was dismantled and Val left ignominiously, albeit temporarily, homeless.

Fortunately, the world of blogging is nothing if not fluid and Dr. Val has found a new home at GetBetterHealth.com. Jump over to take a look. The current set of posted interviews include Mike Huckebee, Grant Hill and Bob Schieffer.

Val writes as a professional author for the site and will have to endure the perils and pitfalls having investors entails. Add to that the natural peaks and valleys that befall the Internet elite and the risk seems even more magnified. Just as Bill Gates dragged computer programmers into the world of pay-for-performance during the 1980's one has to wonder if Val is leading the charge of the next generation of Health Columnists.

Wait Times Earns an Honourable Mention at GruntDoc

The accolades are few and far between in the world of blogging for health care efficiency so I'll take it where I can get it. Check out GruntDoc's caption contest (I placed 4th).

Online Six Sigma Support

In any continuous improvement project I've found one of the major hurdles to be keeping all of the team members on the same page. Grouputer Solutions has come up with an online six sigma tool for everyone to use. Interesting tool -- the link is to the screen shots.

Canada Health Coalition

The CHC published a report this week on the private clinics of Canada. They used anonymous telephone calls to multiple private or semi-private clinics throughout Canada to garner information as well as publicly available information. The study excluded clinics for purely non-necessary medical care (e.g. cosmo clinics) but did include mixed clinics. For instance, some are private but also under contract to a provincial government to provide care as stipulated under the Canada Health Act.

In a nutshell, the Canada Health Act, states that any "medically necessary care" will be provided through public funds. If a province allows private clinics to provide "medically necessary care" for profit then the transfer funds from the federal to provincial governments will be cut by that amount. Eg. people pay a total of 500,00 for private care then the public purse is cut by that amount.

The debate is what constitutes a violation of the Canada Health Act. Enforcement is also variable and subject to the reigning government's belief on private pay care. The report details which clinics exist, which "violate" the act and how they "violate" it.

The CHC also draws conclusions about the impact private care has on health care personnel supply and wait times. They've concluded that it adversely affects both. From a purely scientific point of view, I found the study design of low quality* (anonymous phone survey) and highly biased so I think they've over-reached with their conclusions. I think private clinics have been in existence for too short a time and in too limited a capacity to draw any real conclusions about wait times or their impact on personnel. We could also look to a mixed system such as the UK to get a better assessment of the impact.

That being said, it is a reasonable cross sectional survey of the current situation in Canada and worth a read.

*the asked the front desk person how the clinic used public pay systems. "do I need to bring my medicare card", etc... while biased they also write the text of the coversation so the reader can judge for themselves if the conclusions are warranted.

Parkland Hospital ER Death - More Details

I have a soft spot for Parkland Memorial Hospital. It is a county hospital that sees all-comers regardless of their ability to pay or legal status. I also did an externship there and can say from first hand experience that the ER is amazingly busy and they see about as much trauma as any other hospital in the country.

On September 19th a 58 year-old man died after waiting 19 hours in the emergency room. The event is, of course, tragic and hopefully lessons will be learned. The attached link gives a more detailed description of events, a time-lapse of his wait as well as the coroner's report.

I liked the quote from Dr. Arthur Kellermann from Emory University;

"My hunch is that it happens several times a week in hospitals around the country and it doesn't make the paper," he says. "And that's just completely and totally wrong."

When a clinic tells a patient that they can't be seen for 1-2 weeks what safe guards do you have in place to prevent a disaster? If a 58 year old male called your clinic with abdominal pain how long would he wait? Are they simply instructed to go to the emergency room? Told to call back if symptoms worsen? The lessons reach far beyond ER wait times. It would do all clinics some good to take a look at the effect of wait times on patients.

Lean Nursing Practice Part II

In Part I of this series I discussed what we have done in our clinic to ‘lean’ nursing practices. The last 4 items are smaller but shave minutes every day and decrease the change of having to repeat a task.

Standardized Medical History
Each incoming patient has their medical history reviewed by the nurses. It is an EMR (electronic medical record) and the questions asked are developed in conjunction with the nurses. At one time I worked in a hospital where the nursing history was exhaustive and aspects of it pointless to patients who are admitted for just a day. When developing our own medical history we ask the questions; why do we need this question, is the information provided elsewhere and how many people does it apply to? Like most medical histories, ours is a combination of asking about the disorders that our important to our practice (like cardio-respiratory disease) and ‘shot-gun’ questions that cover all the bases (e.g. “Have you ever been in the hospital”).

Standing Orders for x-rays
Rather than trying to hunt down the doctors for common x-rays on consultation we have standing orders for routine x-rays with agreed upon criteria for repeating x-rays that have been sent by other practices.

Cross Coverage by ancillary services
The nurses’ skills are demanded for complex patients. Other staff will jump in to help when nurses are tied up with a difficult patient for duties that the nurses normally perform (such as organizing which patient is to be seen next, seating patients, simple medical histories).

Emergency Drills
Our clinic practices emergency drills at least once a month in each office. The drills serve two purposes. First is familiarization with infrequently used equipment and procedures. The second is to find broken or missing equipment. There has scarcely been a real ‘emergency’ I’ve been involved in a clinic/ward setting where something is not missing, the best example of which was an emergency tracheotomy where we had the tray, trach tube and local but no scalpel.

Our clinic’s lean six sigma initiatives for nursing are basic but they’ve been effective. If I had to pick one initiative as the most productive it would be decreasing time wasted trying to contact other practitioners’ (doctors) either through a) standing orders b) standardized contact agreements (e.g. phone, page) c) decreasing the need to clarifying orders. For more information a nursing unit in France has published their lean initiative here.

Lean Nursing Practices Part 1

Everdream asked me to blog about Lean nursing practices.

Disclaimer
Our clinics are the equivalent of a ‘surgi-centre’ with both consultative appointments and procedures under anaesthetics. While I’ve been staff at hospitals for years, I have never supervised a floor lean initiative. I have supervised many clinic lean initiatives with our own 20+ nursing staff. For a framework of lean initiatives click here and here and here.

Semantics
Normally I consider initiatives that decrease repetition of a task Six Sigma and initiatives that decrease either the time or variation in time of a task Lean. I think most of us would agree that there is a continuum so all of the listed changes are ‘Lean Six Sigma’.

Goals
Time with the patient
Better Quality of Care

All the nursing initiatives are to increase time with the patient. In our minds, that means defining projects that are relatively small and well defined. They must not create more daily work for the staff. Nurses are not administrators but clinicians. Their time with the patient is at least as important as the doctors.

One of the reasons we never completed ISO9000 was our concern that the paperwork would overshadow the goals of quality improvement. In the same vain, we try not to let lean initiatives distract from the ultimate goal. For instance, endless meetings or daily paperwork that is burdensome are not part of initiatives.

The rest of this blog describes some of the short initiatives we’ve undertaken.

Contacting Doctors
As far as I’m concerned this is the biggest waste of time for nurses. Even in our clinics nurses could spend an hour a day trying to c contact various doctors. In 2002 installed an email server (Exchange) in-house and in 2005 a Blackberry BES Server. The network was necessary and the small additional expense in administration was more than compensated for in nursing time. Now, unless it is urgent, the nurses can simply email the question or request rather than trying to hunt down the doctors. It is not uncommon for me to get an email while talking with a patient from a nurse that is 20 feet down the hall.

When needed for patient in the clinic the nurses also had to search the office to let the doctor know the patient was ready. When we increased the size of the office this had the potential to become a major problem. Now, rather than trying to hunt us down, they will call our desk and if not there page us. Instead of waiting several minutes x 30 patients a day they can move on to the next patient and keep the system flowing.

Equipment:

Sundry Items
The quintessential nursing lean initiative is decreasing how much they walk. I can still remember a friend being asked to wear a pedometer in 1982. We set up each room identically so items are easy to find. We also ‘double stock’ each room with quickly used sundry items (gloves, masks, etc…). Each will have the item in use and a back up. When one runs out they can immediately use the next to save time having to search.

Placing Equipment
When designing our current building consideration was given to the location of the central supply (we are a 20,000 clinic). Central supply houses items used for each case and is centrally located. A supply room holds a weekly supply of materials in the basement.

Broken Equipment
Broken equipment used to go through 2 levels of management before replacement. They would give the part to a supervisor who would give it to the manger who would ok the order. Ironically the nurse was often the one ordering the part anyway. Now the nurses contact the supplier directly and have it ordered for routine repairs. Common items are ECG leads and saturation probes.

Out of Date Equipment
Certain items expire but are rarely used (e.g. defibrillator pads). The expiry date is now kept with the drug expire dates and checked weekly on a checklist

Cost Control
With increased stocking comes an increased cost. Rather than trying to control sundry item cost from the outset we stocked the rooms to maximize efficiency with the patient then re-created our stocking system for ‘just in time’ delivery of most times so that supply costs didn’t spiral out of control. I’ve found this to be a constant battle between preventing a zero-outage and minimizing stock in the basement. It is still a work in progress.


Standardized Training and References (Skills, Knowledge, Judgment)
Uncertainty on what to do in the first two years of the job was common. In 2001 we initiated a standardized training (on-the-job) program for nurses with 2 week, 1 month, 6 month and 2 year goals. Although logic predicts learning should come in the order of knowledge, skill, judgment we’ve found practically that skills, knowledge, judgment is easier to learn. The first month is focused on the basic skills, the next 6 on knowledge and the first 2 years on advanced skills and knowledge. We’ve now added standardized references to the package so nurses have less hunting to do for information. Items include written emergency procedures, common drug monographs, and written basic skills.

Tomorrow I’ll blog about emergency drills, standardized histories, standing orders and cross coverage by ancillary services.

Proud to be a Member

I was accepted into the Healthcare Blogger Code of Ethics group this week. Follow the link in the bottom corner of the blog for more information.

Carbon Taxes and Health Care User Fees

What do carbon taxes and health care user fees have in common?

The Liberal Party of Canada has announced the Green Shift. A tax shift program where industry is taxed based on the amount of carbon it produces. The increased cost incentivizes' companies to find production solutions with a lower carbon footprint. The additional costs to the citizen are compensated through lower income taxes and tariffs are placed to equalize the playing field for non-Canadian companies.

Not surprisingly, the concept is not sitting well with Canadians. In a time of economic turmoil, it's an inopportune time to suggest a new taxation system.

It raises an interesting contradiction in the Liberal Party platform (as well as the Green Party since the agree with the strategy). The carbon tax is social engineering through taxation. Conceptually, there is little difference between it and health care user fees.

Health care user fees incentivize people not to use the health care system. Where there is abuse and overuse the effect is positive. Where there is poverty and marginalization the effect will be horrific. I wonder whether the same would apply to the carbon tax?

Where companies are operating with willful disregard to the amount of carbon produced, in markets where the margins are thick and the competition weak there is no excuse for not lowering emissions. Where technology is lacking, margins thin and competition fierce the carbon tax will cost jobs.

Without taxation, we cannot be strong as a nation. If we hand over the basis for taxation to whatever elected officials declare the latest cause do we run the larger risk of wild fluctuations in revenue? One could equally argue that taxation should be based on homeland defense, obesity, crime rates or any other key issue.

The larger question is do we, as Canadians, want to leverage our tax system to the vacillating opinions and priorities of elected officials.

Health Care Debate Overshadowed by the Economy

In both the United States and Canada debates were held on Oct 2, 2008. I was torn as to whether to watch the Biden/Pallin debate or the Canadian Leaders debate. With the train wreck of an interview Pallin gave to Katie Couric wetting my appetite I wanted to watch the most public I.Q. test ever given.

Alas, my civic duty overshadowed my voyeuristic streak and I watched 5 Canadian Leaders duke it out on National T.V. The video below (in 2 parts) is the health care portion. For international readers, here’s a quick civics lesson.

Canada has a parliament with the Prime Minister being the leader of the majority party. Currently that’s Stephen Harper of the Conservative Party of Canada who, prior to elected office, had been a staunch advocate of privatization of Canada’s health system. The other parties are the Liberals, Green Party, Bloc Quebecois and the NPD. The Bloc is a separatist party from Quebec so they argue most issue’s with Quebec’s interest in mind exclusively where they allow private clinics. The other 3 parties (Liberals, Green and NPD) have come out against private health care.

The Liberals, Green and NPD came out swinging against Harper. Accusations were made that the Conservative's main intent is to allow big businss into health care. There were a couple verbal punches thrown but in the end this is how I saw the facts. All the parties seemed to agree that:
1. excessive wait times and scarce resources are a genuine problem in Canadian health care and not just another political scare tactic
2. many of the problems stem from when the system was underfunded in the mid 1990’s which cut doctors, nurses and hospitals
3. some provinces allow private clinics more than others so there are regional differences in access to care
4. lowering wait times, adding pharmacare and improving access to doctors cannot be accomplished without increasing the health care budget

The Liberals, Green Party and NPD seem to stand united on this issue in their health care platforms. They believe that universal health care means not only a public purse for health care but restrictions on private care to maintain uniform access.

To solve the problem, the Liberals and NPD want to increase funding. The Green Party is looking for cheaper alternatives (e.g. restructuring health care education, expanding multidisciplinary teams, increasing community health, etc…). The Conservatives have slowly increased funding and transfers to the provinces. The have also taken on a few initiatives such as wait times funding, increased electronic health record funding, cancer care and increased spaces for new doctor training as was agreed in the 2003 Health Accord between the Federeal and Provincial governments (not all of the agreements have been met leading to accusations of broken promises).

The 1,000 pound gorilla of course is how and where privatization will creep into the system under Conservative leadership. Both Harper and his Minister of Health Tony Clement have been previous proponents of it and the Canadian Medical Association has just elected a president that runs several private MRI/CT centres in Quebec. Obviously a change is in the wind.

My take on this is that the current situation cannot go unchanged and no-one has the stomach to increase taxes. I believe Harpers' intent is altruistic in that he wants to improve our health care system, even if it does include private care. The Liberals, Green Party and NPD have given scant evidence to the manner in which they will fund health care. During the debate, Elizabeth May of the Green Party seemed to suggest that simply enforcing the Canada Health Act would solve the problems; if it were so simple.

The only alternative left is to allow some privatizations’ (or user fees, which no-one supports) so that people can choose to direct more of their own money to health care. The down side could be that care may become more expensive* as stake holders take their share of the revenue. Another potential downside, could be loss of control over the degree to which we privatize. As a recent NAFTA law suite has shown, opening the door to privatization may also open a can or worms for US health care companies looking to profit in Canada.

Conservatives, at least, have made slow, plodding decisions to improve care and access and I cannot argue with the method so far. I would ask Mr. Harper to apply this litmus test to any change. If a mother is deciding whether or not to take a sick child to the doctor she should not have to consider whether or not the family can afford it.**





*even though there is greater distribution of the revenue in a private system my estimate is that private is roughly twice as efficient as public.
**interestingly mothers make the choice every day now because access is so limited it means a lost day at work almost every time as they wait in clinics.

In Search of Document Management Software

This blog is a technical discussion for people that need to make IT decisions about document management. If you don't care about IT, have never heard of a database or don't need to mange documents I suggest you go have some fun at this web page or this one.

If on the other hand, you've ever grappled with the problem of what to do with that electronic report or fax this blog's for you. Here's the problem. Not all EMR software is intended to manage masses of documents. Most are based on small databases not intended for dozens of users or masses of images (e.g. Access). Larger databases can handle scanned images and many users such as SQL Server, SQL Anywhere or Oracle. One of the main differences is how they handle errors such as when a connection is lost when updating the data. In smaller databases, an error like this can corrupt the entire database. This will become important in a minute.

The smaller document management solutions allow you to scan the document, the program then creates a file folder with an automatic name and saves the new file into that file folder. To relate the unique patient ID to the file folder the programs usually maintain a small database. If this database gets corrupted all links to the file folders are lost and there is no way to figure out which patient belongs to which file folder.

The better way to do it is to store images into a large database. Our offices' EMR is based on SQL Server. It can handle large scanned images (like x-rays and scanned documents) but the 'front end' is inadequate, matching it to TWAIN compliant machines (scanners, camera) is expensive and adding scanned images or documents to it would bloat the database.

The answer is to find a SQL Server based document management software with a TWAIN driver interface that is not intended for a massive company. Opentext and AGFA solutions are more than robust enough but too expensive for our office.

Luckily, smaller companies are starting use enterprise databases (like SQL Server) which are exponentially safer for critical data. The latest company that we're looking at is Dolphin Imaging. It started as a dental product for managing dental x-rays, pictures and scanned documents but seems to have evolved into a low cost alternative for document management. The major benefit is it handles most TWAIN devices and saves the image files to SQL Server.

I've found out the hard way that how document management software stores the images and data is far more important that what the interface looks like. I would warn everyone that before you start scanning all of your patients faxes, lab reports and requisitions into an EMR you check under the hood.

When Henry Ford Built a Hospital

Like many other residents I went for interviews at Henry Ford Hospital in Detroit. I have only two memories. One was the border agent giving me the third degree because I was coming over for an interview and the other is the residents telling me about gunfire in the city on Halloween night.

What was lost on me is that the hospital was built by Henry Ford with economy of motion in mind. I've reprinted Mr. Ford's own words here but I would encourage you to check out the Lean Blog for a detailed account;

"In the ordinary hospital the nurses must make many useless steps. More of their time is spent in walking than in caring for the patient. This hospital is designed to save steps. Each floor is complete in itself and just as in the factories we have tried to eliminate the necessity for waste motion so have we also tried to eliminate waste motion in the hospital."

The reason I started this blog was the presumption that if every clinic could save 2min per patient x 30 patients per day there would be a net increase in the capacity of our entire system of roughly 13%. More than enough to accommodate those without access to primary care*. The next time you are in an appointment and have to search for something give Mr. Ford a thought.

If you changed the system or supplied each room so that you didn't have to pause how much time could be saved during the course of a day?

*roughly 85-95% of the population currently has access to primary care in North America depending on the jurisdiction.