Problems at JPS Hospital, Part 2

Star-Telegram.com: | 04/28/2008 | Trapped in a waiting game at JPS

Update: For those who didn't catch the update to Monday's post, it was announced that the CEO will be leaving, with somewhat of a sliver parachute, I guess.

The first link above takes you to the Monday article in the series about a Fort Worth TX hospital. This article focuses on problems with patient throughput and access:

“I think the emphasis is totally on money. We've forgotten what our mission is: to take care of indigent patients,” said Dr. Wayne Williams, a JPS board member.

The first anecdote in the article is about a patient who allegedly died as a result of poor ER care:

Yet JPS' emergency department is as clogged as ever — worse if measured by the time patients must wait for care. The crowds aren't as obvious, though — they've been moved out of sight.

Doctors and nurses say quantity, not quality, is the JPS measure of healthcare, a concern echoed by consultants who studied JPS operations last year.

Like the employees who “gave up” (as mentioned in the first article), so do patients:

“It becomes a vicious cycle for those patients who know they have a difficult time getting access to the JPS system,” said Dr. Greg Fuller, president of the Tarrant County Medical Society. “So what happens is they give up before they even start seeing a doctor. When they finally get seen by a physician, it is sometimes too late to alter the outcome of what has happened to them medically.”

Bottlenecks permeate the health network at every level. Patients wait weeks to get a doctor's appointment and months for some specialists, like pulmonologists. And when appointment time finally arrives, patients cool their heels for hours waiting to see the doctor.

The hospital is focusing on physician productivity, but in a way that apparently sets quotas. We should remember from our Dr. Deming lessons that setting quotas will inevitably harm quality, as people are pressured to focus on quantity over quality:

Steve Montgomery, chairman of the JPS board, said doctors need to speed up to match the pace in the private sector.

“Why can't they see more [at JPS]? Why are some of them seeing 16 patients a day when private doctors are seeing 30 patients per day?”

There's a ready answer from physicians and other staff: The health problems of the poor are far more complicated. What's more, medical care at an educational hospital, such as JPS, can take longer because the doctors in training are learning as they go.

Dr. John “Jay” Haynes, the chief medical officer at JPS, said the productivity standards do consider the patient's age and severity of cases.

But other doctors object to mandates to see a set number of patients per hour in some departments, clinics and other JPS facilities. Such quotas have nothing to do with quality of care, board member Williams said.

“It hurts quality care,” he said. “And it is a mechanism whereby they can blame the doctors if there are access problems.”

Disorganization leads to wasted employee motion and delayed surgical procedures:

Once in an operating room, things slowed even more. The operations manager ran around trying to find missing equipment and instruments. Nurse assistants, tied up transporting patients, weren't checking the operating room and making sure needed supplies were available.

Those are problems that are 100% fixable, using Lean methods of 5S, standardized work, and waste elimination.

Here's what the consultants identified as caused of delays (with my comments):

1. The hospital doesn't have enough beds, so patients stack up throughout the hospital (what can be done to reduce length of stay? more efficient discharge processes? faster lab results?)

2. Medical records can't be found or aren't up to date (bad processes/systems)

3. Medical equipment and instruments are broken or in short supply. (lack of systems/management focus)

4. Doctors are juggling work in clinics, the operating room, hospital rooms and the emergency department.

5. Some nurses lack experience or are diverted to hunt for supplies. (poor training, 5S, and standardized work)

6. At peak times, there's not enough staff (need to eliminate wasted motion or staff to match demand)

7. Some employees lack the skills or are otherwise unable to do their jobs (poor hiring or poor training)

8. It takes too long to clean and ready operating rooms and hospital rooms between patients (need to use Lean to reduce setup time, reduce wasted motion… better standardized work)

9. Doctors don't get timely consults from specialists or crucial results from labs. (need to reduce batching or improve standard processes?)

10. Inadequate phone systems, a limited window for scheduling appointments and communication problems between the clinics and call centers make it difficult to get in to see a doctor or talk to a nurse.

A commenter asked about Part 1 of the JPS articles, did I think Lean could fix the mess? No, it runs much deeper than that. I hope a real “servant leader” type will take over though, one who can listen and actually start getting people to work together. The community needs it.

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