My hobby, enjoyment, rage everything extracted but just a place where I can put useful information...for myself usually - so I don't forget. I finally separated the conflict on what and where to write. (Although there are tons of personal posts saved here still)
Today I would like to talk about TPS (Toyota production system) and its application in medicine.
I heard about it once in the ward.... that it was being implemented from an ER doc who neither showed positive nor negative sentiment towards it.
I learned a little bit more this morning and maybe it was the fact that so many Japanese words were thrown there that alienated me or the showing of Japanese high school students marching to near perfection shown as an example (?).
My point of initial resistance is: what about cultural differences. While some strategy might work in certain organization in certain country, it might not be a fool-proof because culture, mentality and mindset all differs.
Which also brings me to another thing, I remember that 'habit' is an important thing - or so "The Power of habit : Why we do what we do in life and business" by Charles Dugg stated. Perhaps its not the instillation of new way of seeing patient but the mentality and habit of the organization that needs the restructuring.
What can hospital do to overthrow the sluggish system that wastes lots of money, time and unhappiness?
Do we need all those clerks, nurses, reassessment nurses and etc? How do we standardize such things? where do learners come in?
Ironically, people who were seeking consultations were told to cut staffs first of all, because more people = less efficiency which I can attest according to my experience at Dr.J's office. Good team work between few people versus few people +1 or 2... however that was not on the table so moving on.... they came up with streamline system. Adopting sensei in each part (which I assume would be the manager of the ward), mini sensei and maestro overlooking everything. I quite agree because by having sensei looking at patient first it reduces redundancy and useless 13 steps patients needs to take including seeing reassessment nurse (who would have thought?!?!).
I will explain a little bit about TPS as how I would understand it, basically it means to invest for long term saving. So instead of buying whole bunch of $10 shoes that will last a week and break buy a solid leather shoes which costs $100. In the long run, you saved more at the expense of short-term financial goals.
And Get rid of muri (overburden), mura (inconsistency) and to eliminate muda (waste). There are 7 types of muda and it was identified in all aspects of current ER system.
- Waste of over production (largest waste): There are so many clerks, nurses and etc and they don't share the same humanity after long hours and repetitive works.
- Waste of time on hand (waiting): during 13 steps patient wait in between which results in average waiting time of 4.5 hours.
- Waste of transportation: ambulatory staffs who should be out and about instead of waiting in the hall way for 20 min
- Waste of processing itself: not enough communication and more time spent on writing, typing etc
- Waste of stock at hand: this I understand as resources, I'm sure EDT does an excellent jobs but you have to wonder...
- Waste of movement: Patient and their 13 steps, physicians from pod a, c to b and ...
- Waste of making defective products
The Doctor was saying that 6 hour shift should feel like a 6 hour shift and not 12 hour or where he has to sit down for 2 hours in sofa to kind of reboot. The reason why it would feel like 12 hours is because of lack of standardization of resource allocation whereas the horizontal thinking is constantly interrupted by vertical thinking (I'm not sure if I reiterated him correctly because frankly even after looking up what it means I still don't understand what's what), and because of these constant interruption in thinking and pace (ie.// stamping patients blue card, called by clerks for approval in administrating advil and such ) they waste time and 'resources' that could be used to see and treat patients.
I guess one other uneasy thing I sensed was my understanding to Japanese culture how minimal it was being considered for the implication as being a super drug for the problems. Japanese are strong to weak and weak to strong. They are super hierarchical, so clerks calling on attending physicians here and there or nurses being demanding is something very rare. Actually I doubt you would ever see something like that happening in Asia in general compared to Western practice which I often observe.
Anyways, after streamlining they have achieved very empty waiting room which is amazing but I guess things are still work in progress. However, my curiosity peaked as to how well TPS worked in another country. Instead I find this article in the HBR 2008 edition.
"Quite simply, TPS is a “hard” innovation that allows the company to keep improving the way it manufactures vehicles; in addition, Toyota has mastered a “soft” innovation that relates to corporate culture.The company succeeds, we believe, because it creates contradictions and paradoxes in many aspects of organizational life." (Takeuchi et al 2008). http://hbr.org/2008/06/the-contradictions-that-drive-toyotas-success/ar/1
What's the "soft" innovation?? the article explains as a contradiction. Since I can't pay for the article my research ended there, but I guess that comes back to culture and mentality of the organization and then I read "Contextual intelligence" an article by Khanna in HBR september 2014. (http://hbr.org/2014/09/contextual-intelligence/ar/1) and my sentiment towards this new system was echoed by the article. "Trying to apply management practices uniformly across geographies is a fool’s errand, much as we’d like to think otherwise....That’s because conditions differ enormously from place to place, in ways that aren’t easy to codify—conditions not just of economic development but of institutional character, physical geography, educational norms, language, and culture." (Khanna, 2014).
However, I think now after hogging this for a while criticism isn't a criticism if it's directionless. I just organized why I was being uneasy with the idea but I haven't really stated what could possibly improve the state of:
long waiting time,
grumpy hospital workers
redesigning doors (nick name: granny killer, petri dish)
streamlining patients (what's the most effective way? how do we have them not tell the same story x 3+)
I think about this because I have been a patient first and I waited with my families. The excruciatingly long waiting time, redundant testing which I thought was weird... etc.
I guess I think about how I would not want my parents to be ill-treated.
As of yet, I have no other plan that might works. While I applauded the progress the doctor was making especially with the resistance from most senior persons. However, I do agree that as soon as patient registers at the front desk with some history being taken, patient should be seen right away by the physician - for example, drug addicts seeking extra drugs should not occupying the chair for 9 hours. What seems to be less critical or urgent but still give patient excruciating sensation of pain should be looked into - and they should be administer with some kind of medication instead of having to suffer more than is necessary.
I guess it would be patient-by-patient and case-by-case but I'm sure physicians would make a good decision, especially the resident who points out the problems such as that he was ready to work at 8am, and had to wait for admin staff for 45 min for instance of pointing out that learner should not be the problem the physicians should consider in a newly streamlined process because if attending physician spends 5 min to talk to them they do 10 min of work so it would save time and instead of attending physicians dropping for the difficult case and have residents do everything, it should be the physician who does the bulk and residents who help him/her (although if the workload decreases that's probably bad since residents needs all the exposure he/she gets.
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