20 Oct, 13 | by Toby Hillman
There are several problems which rear their ugly head every few months / years in healthcare and yet seem impossible to crack.
In the main they pass by, unnoticed by the great and the good, and not usually causing discernible problems for patients. But, time taken to gather phlebotomy equipment, delays in prescribing ‘TTAs’ and ordering too many tests are all a waste of resource.
Waste is the enemy of efficiency in any system, and the 7 wastes:
- defects in work performed
are the target of many improvement projects (especially those relying on lean thinking)
One such improvement project has shown a successful, and sustained reduction in the waste of excessive laboratory tests.
The paper reports the process undertaken to introduce a change in the practices of an emergency department, through a forcing function of only allowing junior staff to order tests once a senior had approved the request. The largest excesses in requests were targeted and significant changes over time were achieved.
The report puts some of the change into context, but I wonder if a follow up, qualitative study might be required to really evaluate what changed.
I may be wrong, but this intervention doesn’t seem like one which was imposed rigidly from above, but instead was developed in collaboration with the key clinical decision makers in the department, and with an eye on what would actually work on the ground – in *their* department.
And this is the messy bit.
For senior clinicians, and managers who see the headline: ‘Change in form reduces tests, saves $$$‘ there could be a shock coming.
Firstly, the change took time to bed down – see the histograms for the weeks after the intervention – so no quick fix.
Secondly – don’t kid yourself that it was the change in the form which made the difference – it was a shared vision for change from senior, middle and (probably) junior grade doctors. After signing up to a shared goal, there was a change in working practices, backed up by a staffing and service delivery model (note the absence of a 4 hour target, and retention of responsibility by the ED for short stay patients) which encouraged a dialogue between seniors and trainees. Moreover – and crucially, in my view – the change opened up the possibility of real-time, on the job, training.
Each interaction for an additional request seems like it will have been a discussion point – and trainees benefitted from a culture of learning within the department.
So, could this be reproduced in the UK? In some departments, I’m sure, in others – no way.
In trying to replicate such successes we should not concentrate on the mechanics of the intervention, but the human factors and cultural context. Work on that, alongside such innovations and you stand a much better chance if success.
For more information on human factors (if you’ve not heard the phrase – look it up – it could change how you view your world and where you work) then see the Clinical Human Factors Group and an inspirational video on human factors in patient safety from the incredible Martin Bromiley: