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CRC - Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management

Organization: CRC
Publication Date: 29 October 2012
Page Count: 289


Kenji was frustrated. It should have been so much easier, so much faster. The changes he expected to see weren't there. He found himself trying more and more often to prove to his boss that his efforts were, or perhaps would, have an impact on the bottom line. Though he could see, even sense, the change that had taken place, the CFO couldn't count it, so it might as well not be happening.

It had been almost three years since the dream he had while sleeping in a metal chair in an emergency department (ED) waiting room rattled his cage. That dream, that nightmare, had stirred something deep inside him that made him leave the world he'd known since college, his manufacturing comfort zone, and step out into a whole new world of healthcare. The work was different, very different, from anything he'd seen in a factory. The intense work of analysis, the preaching, teaching, begging, and arguing for every minor incremental improvement, all seemed worth it when he started. But now he was beginning to wonder.

His son, the reason for his late-night visit to the crowded ED on that fateful rainy night, was so proud of him when he announced that he was leaving the Toyota plant that had been so good to him and his family. Toyota treated its employees well, and there was never any real threat of unionization in this traditional Southern town with its ingrained work ethic. It was therefore a tough choice-one that would see a cut in his pay, benefits, and career progress-but one he never questioned.

Though healthcare was new and very different, what he'd seen made him initially believe that it was a world he could fix. Change was to have come easily and swiftly, given how broken the system seemed to be. He'd suspected that even small improvements should show up as huge benefits. His long history of change management in manufacturing assured him that he could lead his new employer to a higher level of sophistication and productivity.

His new job at the local hospital, secured by interviews set up through well-connected neighbors in his subdivision, was to "fix it." "It," as it turns out, was just about everything. The emergency department was "broken," which was apparently hospital lingo for "completely and totally dysfunctional." The operating room (OR) was mostly run, or rather lorded over, by a small cadre of politically powerful surgeons who seemed to hold the chief executive officer (CEO) in the palms of their hands. What they asked for they generally received. What they didn't like generally did not happen. And they didn't like Kenji's ideas.

In his manufacturing days, if the paint line was slowed down, it impacted everything upstream. This was both intolerable and quickly fixed. Kaizen teams would descend on the problem area like gulls to a clam, picking at it until the problem was solved. The upstream work cells would be as demanding as the downstream bottleneck cell, since everyone's compensation and/or bonus was, in some way, tied to the productivity of the whole plant, not just their particular cell. All worked together as a unified army, bent on the absolute annihilation of any and all waste and inefficiency, no matter where the root cause lay.

Kenji sat at his desk in his stark, windowless basement office, just down the hall from his hospital's purchasing department and linen services. Here, surrounded by whiteboard covered with scatterings of ideas and process maps, he thought about his "good old days." He smiled wryly as he thought back to the project one of his teams had undertaken at Toyota to ensure that the men's room near section 45 was cleaned more regularly. Within a few hours of working with the janitorial staff, they had literally value-stream mapped the entire bathroom cleaning process, 5S'd the cleaning carts, and scheduled the workload to allow the janitors to clean the bathrooms when it would do the most good. Quick work, quick solution, even if to a very minor problem. The janitors were, at first, too shell-shocked to argue, and frankly didn't care much about it until they realized how much easier their work actually had become. They walked less, accomplished more in the same amount of time, and were even given the incentive of an extra thirty minutes of break time at lunch if "customer satisfaction" (i.e., men's room users) scores remained high. Ironic, he thought, that similar results on a similar project at the hospital might take months to come to fruition. And, as Kenji thought back, he was pretty darned sure that his old boss never challenged the financial significance of that project. It was never about the finances. It was about the workers-his friends, neighbors, and fellow citizens-at the plant.

He snapped back out of his stroll down memory lane to look around his office. Value-stream maps of the ED. A Kaizen event that planned for discharge processing. A 5S in the cardiac care unit (CCU). It struck him again, as it had months before-that both the problem and the solution lay in these many projects. It wasn't the projects themselves that were the problem. Had this been his factory, these would lead to improvements, to some degree. They had potential to do the same at his hospital, too. Here, though, the projects were all individual, isolated projects that would likely not lead to the massive, systemic improvements his boss wanted. Rather, they would lead to siloed impacts that often created more problems than they solved, assuming they actually solved anything substantial. Oh sure, he could fix ED triage, as long as there was physician capacity to see more patients when the boluses arrived into the main ED from the triage area. Those were the simple projects. But the downstream, external department silos-well, that's another story.

The silos. Hah! More like fortresses! They were fortresses armed with archers and cannons and boiling oil to ward off any change agents who might try to enter from another, equally hardened fortress. Worse, each silo had its own internal issues that made changing one risk negatively impacting another. This made the second throw up its defenses against any changes within and without. Even if he could penetrate them all at once, as he'd been trying to do for the past three years, he wasn't sure that he could piece together the entire system into a coherent picture and a systemic, quantifiable goal. It changed so much from day to day, week to week, month to seasonal month. This constant change and the constant battles between fortresses made him feel like a man in a huge field chasing rabbits. The minute he got close to one, it would dive into a hole and pop up somewhere else in the field. He could never catch up. All his Lean training did not prepare him for such a crazy, chaotic world.

Not that he wasn't trying everything he knew to try. To help with grasping and analyzing the complexity of the system he was trying to fix, he'd put in a purchase request for a simulation tool that he'd seen at a healthcare conference. He'd seen a presentation by another management engineer who'd used a simulation software package called Arena to replicate the flow of a patient through the entire hospital. Wouldn't that be cool, he'd thought. He researched the simulation vendors, and chose the most popular one on the market, in part because they were so supportive of the industrial engineering schools and societies, and in part because it was used by the presenter's team. Alas, however, his Arena software purchase request was buried somewhere on his boss' desk awaiting next year's budget cycle. Maybe he'd see a license in eleven or so months. Like a carpenter without a good hammer, he'd have to find a way to make progress without the right tools. He scoffed, maybe if one of the orthopedists would make the request, it would be on his desk by Friday!

He shook his head and vowed, as he did every day, to march on. Just as he was about to leave for a 10.30 a.m. meeting with the nursing director on 4-west, the phone rang. It was his wife. A shiver went up his spine, just like every other time she called now that her mother was back at home instead of in the nursing home. Was today the day he'd get "the call?" The thought itself turned his stomach queasy as he reached for the phone. "Hi, baby. How are you? Can't chat but a minute or I'll be late for a meeting with Janet Savage. What's up?" he asked, hoping for a good answer.

"It's mom, honey. She's taken another turn for the worse. And I cannot get Dr. Goodall on the phone. He's off today or something. The answering service picks up every time."

"What's the problem?" he asked, while simultaneously looking at his watch and feeling guilty for doing so.

"Her weight is up another few pounds since last week. Her breathing seems more labored. At least I think, I can't remember. She says it's not, but I think it is. She doesn't look well, and she says her chest is still 'cramping,' whatever that means. I might have to take her back to the emergency department if Dr. Goodall cannot see her right away. I'll bet that's what he tells me to do anyway, if he calls back today. I think he's off. I certainly cannot figure out what's going on, and I'm no doctor."

Great, he thought. Just what his ED and Nana (as the family called her) don't need-yet another trip the ED for her chronic obstructive pulmonary disease (COPD). Or was it her asthma, or her two bum knees, or the chest pains that put her there last time? It's not like we don't know what she has! Yeah, he recalled, she was just admitted to the hospital, what, a few weeks ago for her COPD. And now she might have to go back? Is there a revolving door on this place?

Kenji knew Dr. Goodall. He was a caring physician with a soul of gold. He was very near retirement (assuming, he routinely joked, the government lets him and his portfolio doesn't hit zero). But he was still seeing a full load of patients. He worked "the old fashioned way," the way a lot of docs still do-a lot of hours, a lot of rounding and phone calls after hours, a lot of early mornings and long weekends. He was one of those who had medicine in his blood since he was a kid. And, good or bad, he was still a believer that medicine was 70 percent art and 30 percent science. In other words, this was not a doc who would be using a computer-based algorithm to help create a care plan.

Yet, for all his commitment, the system wasn't supporting him well. His small office staff was a dedicated group that worked hard to take care of his patients. But they too struggled. Both their antiquated computer systems and the latest software gave them regular fits. Dr. Goodall chased specialists for opinions, while the specialists chased down results of someone else's last lab orders. Kenji's mother-in-law was not well, so she saw a lot of doctors in the community, and was a classic example of the complexities of disjointed care delivery. None of them seemed to communicate with each other, at least not readily or easily. It seemed such a struggle just to get a coherent set of instructions for one of her conditions, let alone all of them. Worst of all, he thought, they always seem to take time off when Nana gets sick.

Of course, his mother-in-law was often her own worst enemy. Compliance was a foreign word, one that meant little or nothing. Inconsistency and stubbornness were more characteristic than following directions. She was just not a good patient. She cancelled as many appointments as she kept, which meant her care was sporadic at best. Small wonder her conditions were so hard to treat, or that one of her specialists had threatened to stop seeing her.

And talk about fortresses! There were so many it was hard to count them all-the specialists, the offices, the hospital, the clinics, Medicaid. How many phone calls had his wife made from her office, during breaks or her lunch hour, to try to get answers that should be readily available?

Perhaps most concerning about Dr. Goodall was his imminent retirement. It was a mystery where his patients, especially Nana, would go when he left his practice at year's end. None of the other docs in the area were taking new Medicaid patients, which meant his wife's beloved mother might not have a primary care physician (PCP). Without Dr. Goodall's tender and forgiving spirit, who would put up with Nana and her crazy attitude?

"Should I just go ahead and take her in, honey? She's not going to get better sitting at home alone. And I can't take off work tomorrow because I have a board meeting to attend. Today is the only day I have to wait in the ED. She's got no one else, and nowhere else to go." And wait she would, he thought. If only his employee status could jump her to the front of the ED line, like a Platinum Club membership on an airline. She was, after all, a frequent user! "I dunno. What's she like?"

"Alone. Confused. Stubborn. Just like every other day. Baby, I just don't see that I have a choice. How bad is the wait today?"

He wished he could tell her, and he should be able to, but he didn't have the first clue. "What else can you do, baby? Take her in, I guess. I just wish the doc would see her first."

Kenji left for his meeting with the unit manager, knowing where Nana would be within the next eight hours-probably on Janet's unit. Then, back out of the hospital to cycle back through again. There had to be a better way, he thought.

As he walked the long hallways and climbed the stairs to the fourth floor of the aging facility, he passed a window that looked out onto the center of his small town. He paused there and thought about his Nana, who was only one of many elderly in the area. She was blessed to have him and his wife to help tend to her needs. Many were not so fortunate, yet he had a suspicion that there was more that could be done.

As he walked on after his short pause at the window, he thought of the folks in this community. The entrenched organizations, like the local Elks, the Lions club, and the small YMCA that had just been renovated. Seems there was a church for every ten residents around here. And a lot of health problems occurred every hour of every day that his hospital would never see or know about, probably because his hospital was its own fortress. Certainly, new ideas could not penetrate its hardened walls. He knew that, with his siloed focus on the individual fortresses within this hospital he'd never even begin to understand all the complexities that lay just outside the doors in the surrounding medical community. He wondered, is it as chaotic and inefficient there as it is here? Surely it's better out there. Yet, based on Nana's experience, he knew otherwise.

He began to consider the problems his community faced. People like Nana, with nowhere to turn but his ED and hospital, maybe a PCP if they were lucky. The problems he was facing in his hospital seemed to pale when he thought about his hospital as only a piece of the larger puzzle. An important piece, mind you, but a seemingly small piece when he considered all the care that was delivered outside these walls. Probably a thousand office visits and consults for every ED arrival. There, he thought, is a much bigger conundrum.

He began to wonder how much his hospital might actually contribute to the problem, and whether or not the hospital leadership even realized how they interact with the rest of the community. Suddenly, the problem with ED triage wait times and discharge processing began to take on a whole new meaning, one with a broader implication than just the ever-precious Press-Ganey scores. His departmental problems spilled out into the community, to Nana and everyone else in his little town. It was like a dead canary in a coal mine- a warning of the cause and effect of the issues around him that he could not yet see or impact.

As he leaned against the pale yellow concrete walls of the old hallway outside Janet's office, he realized that this was going to be far harder, and infinitely larger, than he'd ever suspected. What on earth had he gotten himself into? Was there any way to heal Nana from a hospital bed when she couldn't, or wouldn't, see her PCP when she gets back out? Suddenly, the hospital felt very small and insignificant to him.