My hospital had a complex problem: throughput. ED boarding was high. There were unexplained excesses in length of stay. To attempt to resolve this problem, many strategies had been deployed: lean-process changes, consulting companies to redesign workflows, data sharing. To me as a team leader, it seemed an impossible challenge. My team had many competing priorities and frankly did not know where to start. But we did start, and eventually make headway. I discovered four principles during the journey, which now make up my “thinking framework” to solve complex problems.
1. Begin at the beginning.
One day during our weekly team meeting we were discussing how to redesign our daily interdisciplinary huddles to improve throughput. I was sharing data on length of stay, discharge orders before 11 a.m., and excess days in an attempt to motivate change. I opened the floor to my team members for questions and comments. A senior hospitalist asked me, “What is throughput?” It was a simple question, but it made me realize the importance of establishing a groundwork for problem solving: What is the issue we are attempting to solve? We must take heed not to overlook the simple things. Common, everyday language can go a long way in explaining complex administrative jargon. In this case, we explained the problem in several different ways. We shared numbers for those of us who are driven by competition. We shared financial statements for those who have business acumen. We shared literature for those who are academically inclined. Each member on the team must have a clear understanding of the problem. Begin at the beginning.
2. What's in it for me?
Hospitalists get inundated with initiatives and process changes. It is an environment of multitasking, with some tasks seeming to be in direct conflict with others. Aligning a project with an individual's core values is critical for successful adoption of change, and more important, continuation of those changes. We may not consider throughput one of the instinctive goals of our training. It doesn't speak to our ethical framework of practicing medicine. Hospitalists may wonder, “How does a decreased length of stay impact the patient?”
To answer this, patient stories can be a powerful tool—the patient who was boarding in the ED for 16 hours, or the patient who could not get into our tertiary facility in time for a neurosurgical procedure due to lack of beds. These stories make us realize that throughput is in fact part of the practice of medicine. They speak louder than metrics ever could.
3. Us and them
Collaboration should not be assumed. It is a learned skill. A big challenge we faced was everyone's perception that length-of-stay management was someone else's responsibility. This belief was detrimental because it was pitting different disciplines against each other. Deliberate steps to ensure seamless alignment between case management and front-line hospitalists were essential for successful discharge planning. To solve this problem, we conducted education sessions about the hospital throughput initiative together for hospitalists and case managers. Performance metrics were shared with both parties.
To strengthen collaboration, we created an internal review team that can now be activated to start a multidisciplinary discussion regarding difficult-to-discharge patients. The team includes hospital executives, the chief medical officer, ethics committee members, the risk manager, the attending physician, and hospitalist and case management leadership. One such review involved a patient who needed extensive wound care but was not able to care for himself at home. He did not have resources to access outpatient services but didn't meet criteria for further hospitalization. The forum provided an opportunity to discuss everyone's concerns, including the risk of complications, liability, moral distress, and prolonged length of stay without medical necessity. There were different positions on whether to discharge the patient or not, but whenever there was conflict, we redirected the focus to our common interest: providing the best possible care in an efficient manner. Eventually the problem was broken down into smaller pieces, and collectively a creative solution was found. The hospital temporarily covered the patient's wound care as charity care until his family arrived from out of state.
It is not us versus them. It has to be us and them.
4. See something, say something.
A good process should have clear guidance on what to do when things are not working. When clinicians encounter barriers to care that are seemingly outside their control—a delayed MRI, lack of outpatient resources, a pending consult—lack of direction can be very disengaging. The process to report a problem should be easy and efficient, so we created pathways for real-time escalation and provided easy access to hospital leadership. We encouraged front-line clinicians to report avoidable delays in patient care they encountered, so trends could be established based on their collective feedback. One issue identified by this process was a delay in nuclear stress test reporting, which led many patients to be kept in the hospital until the end of the day even though the test had been completed in the morning. Root-cause analysis showed that test readings were being batched and the workflow was changed to decrease delays.
We put out a clear message—if you see something affecting throughput, say something. This empowered the front line to make the invisible visible. To encourage the reporting of problems and concerns, it's important to create a safe environment with closed-loop follow-up, irrespective of the outcome. Team members have to know that their voices are heard and an honest attempt is made to resolve every issue.
Hospital medicine is changing rapidly, and team leaders must constantly strategize and lead to manage change. I hope this four-step thinking framework that I have developed will help other leaders engage their teams to solve complex problems.