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Fractured – Waste in the Medical Clinic

Earlier this week I had to take my daughter to the fracture clinic to get her leg checked out. She had broken it 4 weeks ago and it was check up time. It was interesting when she 1st went to get it check out when it happened. On the original visit hey had asked all sorts of questions, decided on an outcome then thought, actually we should Xray it just in case, but it could be a virus, so we will also take blood. That did not impress the daughter as she is not keen on needles, who is at 11 years old? They X-rayed it and the result was "hmm not sure, it could be a break, but it could be a blood vessel". So, the decision was put a compression bandage on, take some pain killers and call us if it gets really sore. 2 days later we were back because it was really sore. This time a new doc looked at the Xray and said well its obviously broken, you should have had it in a leg brace. That was 4 weeks ago and now we were back for the review, with a daughter keen to get out a leg brace and back on the netball court (she is her school teams main goal shooter).  

The Return Leg 

We got to the fracture clinic for the review at 2:25pm for a 2:30 appointment. We were met at the door and checked over for COVID19 symptoms, handed a mask and sent through to the fracture clinic waiting room, my lean waste brain kicked in and I started counting. 15 minutes later we were called and to go to a cubicle (waiting). Another 10 minutes and a doctor turned up (waiting) to ask a few questions, looked thoughtful and decided we should go round to get an xray since he couldn't make any decision without seeing how the bone was healing, even though it sounded good. He left saying he would get a nurse to organise the xray, 10 mins later he popped his head in ... how was the Xray? Nope haven't had it yet... (Defect) so of he went to chase that up (rework)… 10 minutes later we were returned to the waiting area to be called for the X-ray Total time with Doc.. 4 minutes.

We returned to the waiting (motion & waiting) area to be called for the Xray. 10-minutes later we were called for the X-ray. 2 Xrays were taken and the daughter was then returned to the waiting room to go back to see the doc (Motion & Waiting) Total time with Xray - 7 minutes

During this time the waiting room again filled up with more people waiting on their appointments, one by one they were taken and with a few notable exceptions most seemed to be filtered back through the Xray and back to the waiting room.Everyone has an appointment, so it is not a surprise they are there yet pretty soon there are no seats left in the waiting area.

45 mins (waiting) after the Xray I chased up the medical staff to find out what was happening, they were unclear about what was next (defect) but would check with the doc and get us shortly. 30 minutes later I did some rework by asking again, still same answer. 20 minutes slater I spotted the doc and managed to corner him, he looked a little confused, why are you still here??? (defect) well you haven't told us about the outcome of the Xray or the next steps.

We were then ushered into the room and the doc looked at the Xrays which are all digital now so were available on his desktop even before we had returned to the waiting room from the Xray. My next door neighbour is a radiologist so was able to tell me about the great speed they can do this stuff at now, that however seems not to actually be a bottleneck just capacity that isn't getting used (over production).

The doc looked at the Xray and said, yep it's healing fine, don't need the brace any more and you should only need 1 crutch for the remainder of this week and that's it, then leave it 2 weeks and you are good to play netball and be an 11 year old girl again. My daughter was not impressed at this 1 because, as she pointed out, she never stopped being an 11-year-old girl and 2 another 2 weeks without netball is an age away! I'll get you an appointment for 2 weeks' time just to check. Total time with Doc.. 6 minutes.

The doc also made a big deal about us not waiting around and that we should have been chasing them more!

He then disappeared to find a nurse to make the appointment, in the same office as we had been in at the PC next to his. She came in, then had to go out to get more paper to print on and finally, a further 7 minutes later, we had an appointment and could leave. Hopefully in time for the daughter to still make her guitar lesson

The Diagnosis 

Pardon the really bad pun but it's clear that the process here is fractured or worse just broken! Obviously, there is no way of knowing if there should have been more than 1 doctor on duty so was more stretched than normal or if some cases were more complicated than expected but there are a few things that jump out here.

1. No Patient Flow 

The system works by moving people from one waiting spot to another, each time you have to move and then wait for the doc to come along, could some of that be given to nurses? What if the doc pulled patients only when he was ready to see them? Since the Doctor is the constraint the approach is filling rooms and he runs between the rooms, that means you need more rooms and more waiting spaces. What is like at the GP you came to the Doc or some of the initial test or assessment work was handed off to the nurses? (think non utilised talent here)

2. No Standard Work 

Since they know who is coming in and what for then they can plan both the capacity required each day and the patient journeys and set up standard work routines for the various standard ailments that come in. In my daughters' case it should have been arrival > X-ray> Doc for example that way the 1st time the doctor sees her he has all the information he needs to make a decision and what the next steps are. I think if you did it this way the time with the doctor would be less as well, I'm sure our total time would have been around 12 – 15 minutes and we wouldn't have waited so long!

3. No Visual Management 

There was zero visibility of where each patient was in their treatment journey, no way of knowing that you had seen someone or that you had to see them again or how long they were waiting. A simple magnetic white board with whiteboard magnets that you could put names on and move around on a hand drawn a Kanban board would show you exactly where the patient is, and how long!

4. No focus on the Customer 

People feel it's wrong to think about a medical clinic as a business or patients as customers but it's exactly what they both are. Can you imagine a business who delivers the product late saying to the customer well you should have complained earlier, and we would have put more focus on delivery? Do you think they would still have the customer? By examining or value stream mapping what steps need to be taken to minimise the time the patient is there and maximise the use of the medical staff improvements would certainly be found.

The Waste Bill 

The waste in any system is paid for either by the customer with higher prices or by the company through lower (or no profits) The level of waste in this process are pretty high, and it also needs to be funded and it's funded by the tax payer, insurance companies and the patients. In addition to the obvious costs the additional opportunities costs need to be thought about, how many other patients could have been seen, how much less room would you have needed if you had done it right, linked to that floor space reduction is a reduction in the running costs or heating / lighting etc .

The bill for waste needs to be really understood and not just calculated superficially in order to really understand the power of removing the waste in the systems.

With small tweaks to the process here we would have removed over 3hours of waiting, seem more patients and had better outcomes for everyone.

So it's time to look around at what you do, look for the waste and think who pays for that, what else could you do if you didn't have the waste, then go and attack it as hard and as fast as you can.

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Wednesday, 30 September 2020

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