Lean Health Care – Humble Before People

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When I decided to blog I made a rule that I would NOT post on lean health care for two reasons: I have never done health care, it has only been done to me, and there are other blogs that are prolific and profound on the subject (here’s one.)  But rules were meant to be broken, right?

The story begins with Fred Holliday who goes to the ER for pain in his lower chest / back.  It turns out that he has a broken rib.  Why does he have a broken rib?   Because his previously undetected kidney cancer has spread to his ribs.  It’s bad news — he has stage IV kidney cancer.  He needs to be transferred to a new hospital but before he is admitted and given any pain medication or even fed, the new hospital needs the records from the old hospital.  His wife Regina goes back to the old hospital to request the her husband’s medical records and is told that it will be 73 cents per page and a 21 day wait.  She went to a local pizzeria to get him something to eat because the new hospital wouldn’t feed him before properly admitting him (which couldn’t happen without the medical records).  When he got to the second hospital he needed hip surgery for a broken hip which he received at the first hospital when an orderly bumped him into a wall while he was on a gurney.  He had been complaining about pain but nobody in the first hospital had followed up.  The pharmacy at the second hospital refused to order his chemotherapy drug because it was too expensive even though it had been approved by Fred’s insurer.  Fred’s Doctor explained with, “Sometimes this happens.”  Regina ordered the drug herself.

I’m not sure if these problems shortened Fred’s life.  The broken hip certainly didn’t make his last months any more comfortable though.  It’s not the stuff that he and his family needed to be dealing with in his last few months.

Obviously some system failed (the first hospital claims that it is routine to send records with patients – the second hospital claims that it is not unusual to receive a patient without medical records), but should it take 21 days lead time on medical records in a case like this?  Can’t somebody intervene on the patient’s behalf when systems fail like this fail?  My beloved Marine Corps screwed up my pay once, and when dispersing said that there was no way that they could cut me a check before the weekend my Sergeant Major (highest enlisted rank – not to be messed with) told them that was fine, he would send me by their office to pick up the cash shortly.  Henry Ford had expeditors that he sent through his plants to make things flow when they weren’t.  Of course getting to root cause and implementing systemic solutions is the right thing to do, but when your customer is a stage IV cancer patient why not take containment actions.

There are a bunch of morals to this story.  I think the one I want to point out is to be humble before people. I have heard that when there are systematic errors on the line at Toyota that the Process Engineer responsible for that part of the line apologizes to the people on the line for letting them down (I have never worked there so it may be apocryphal but it makes a good point).  I don’t suggest that we should blame the people involved in Fred’s problem (there are probably systemic causes behind them), but it would be reasonable to think somebody could make copies of medical records in less than 21 days when that constitutes a significant percentage of the rest of the patient’s life, take an x-ray of the patients hip when he complains of severe pain after being bumped into a wall, or follow-up the pharmacy so a patient can get his pre-approved chemotherapy drugs.  Call them containment actions where we take immediate actions to stop a system failure from propagating out of control.  Is it reasonable to expect people to step up in situations like these?  Am I blaming people? Please fel free to comment.  I look forward to your feedback here.

There were other problems in Fred’s last few months.  He didn’t get a very good diagnosis up front, his ‘blood count’ went bad and that got noticed late because the rehab unit he was in only did blood work in the morning, no exceptions.  You can read the story here, or read and listen to another version here.

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One Response

  1. I read the first few lines of this post and had to quit, my head was shaking too much. Health care (the system of or the delivery of care) is in the dark ages as far as systems and systems thinking. Part of the culture in health care is “if I study harder, work harder” bad things will not happen. There is a tremendous expectation of personal accountability that is part of the training health care worker go through. I don’t know if I have an answer to anything on this topic but we are partnering with university industrial engineering department to help educate and implement industrial and systems engineering principles to the hospital wards and clinics. It has been exciting, but the leadership still needs to be brought up to speed with what the capabilities are. They are still thinking in the traditional health care training mindset.

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