Friday, October 17, 2008

Suggestion Box

Last week's staff meeting reminded me of one of the world's most famous companies. Or at least, a book I'm reading about that company.

It was a great meeting. We welcomed some new staff and oriented them to our Advanced Access project. Over lunch, we discussed staff suggestions for Clinical Practice Redesign.

A few weeks ago, we set up a suggestion box in the staff area. It sounds like a corny idea, but we wanted to see if it would encourage people to share thoughts on how we can improve our office processes. It really paid off. While none of the ideas are earth shattering, I think they'll have an immediate effect for office workflow, and they illustrate principles of quality improvement.

Which brings me to "How Toyota Became #1 – Leadership Lessons from the World's Greatest Car Company" by David Magee. He tells the story of the development and practice of the Toyota Production System, Toyota's approach to management and quality improvement. Several of our staff's ideas reminded of the principles Magee writes about. Here are some of the ideas we'll be implementing.

Post-vasectomy notification

After men undergo vasectomy, they have lab testing about 2 months later, to make sure that they're sterile. It's important for them to get the results of the test before they and their partner stop using contraception. Some of our doctors notify men by letter, others use phone calls. However, calling a man about his post-vasectomy results doesn't always take priority over other phone calls, such as biopsy results showing cancer. As such, it may be many days before we call the man. Being anxious to hear about their results, many men will call our office, and our staff will leave us a message to call the man back.

In order to get results promptly and reliably to men, without receiving a lot of phone calls, someone suggested we routinely generate a letter to the man, as soon as the post-vasectomy test comes back showing "all clear." Our staff would make up the letter and show it to the physician, who will confirm the test result before signing the letter. A phone call would be faster, but only if the physician actually makes the phone call as soon as test results are available. As noted above, making that call isn't always a relative priority.

This was an example of having the right person do the job (i.e., receiving the result and generating the letter will be done by staff – the only function that demands physician attention is confirming that the result is "all clear") and standardizing the process to reduce variation and waste. We'll be adding a note to the letter men receive when being scheduled for vasectomy, telling them that we will notify them of their post-vasectomy results by mail. This should cut down on unnecessary phone calls.

Staff communication via EMR notes

Our electronic medical record (EMR) has several categories of notes (phone calls, clinical notes, etc.) that we can add to patient charts. Physicians use these extensively to document phone conversations, prescription renewal and other clinical information. Our staff haven't used this feature much.

A staff member suggested it would reduce wasted time if all staff recorded conversations with patients. For example, a staff member may call a patient on Thursday to give instructions about a CT scan booking, but not get an answer. The patient may return home later that day and see our number on call display. They'll return the call on Friday, but then a different staff member will take the call. As there hasn't been a note made on the patient's EMR, that staff person doesn't know why the patient was called and then has to canvas everyone in the office to find out why the call was made. According to our staff, this is a common situation. There were other examples offered where more thorough documentation on the EMR would improve office workflow.

In his book, Magee mentions the concept of horenso used at Toyota:

"Derived from the Japanese words hokoku (giving a thorough update to somebody), renraku (staying in touch on a subject), and soudan (consultation about an issue), horenso… is a detailed progress report on issues or problems that is used for self-remembering purposes and for leaving a trail of explanation for coworkers and superiors."

The suggestion was simple enough: staff should document, on the EMR, all interactions with patients. However, some staff may not have known that they could use EMR notes to communicate this way. Up until now, it had been solely physicians using this feature and we never "gave permission" for non-physicians to use it. Now, they have explicit permission to use the EMR. Since the meeting last week, I've already noticed a marked increase in the use of EMR notes by staff.

Organizing the paperwork

We have forms. Lots and lots of forms. Lab, X-ray, nuclear scans, prescriptions, OR booking, etc. Each physician stores these forms in idiosyncratic spots: desk drawers, piles on top of desks, cupboards. Staff have to restock them regularly, and so have to figure out 9 physicians' hiding places.

The solution: standardized file-folders in a container that will sit on each physician's desk. Each commonly used form will have its own labeled folder. Staff will be able to check a consistent place in each physician's office to restock forms.

This solution may seem simple, boring, or even blindingly obvious. And it is. But the beauty of it is this: our staff hatched and executed the idea without waiting for "official approval."

More from Toyota/David Magee:

"The formal employee contribution system gave workers a way to directly participate in decisions that made both their work conditions and the overall company better. It was based on the premise that the boss cannot see and know everything that workers are able to observe daily while doing their jobs."

I think this is a sign that enthusiasm for Clinical Practice Redesign is spreading in our office. The suggestion box is turning out to be solid gold.

No comments:

Post a Comment