Posted by: knightbird | September 15, 2010

Crutch Positions and Lean Management

I have talked about Crutch Positions in the past in the context of Chugachmiut. We used to create positions that would do parts of another positions jobs because of a lack of training or experience. We had a full time budget officer that interpreted budgets to program manager staff, and did financial transactions for and with them. The Alaska Native Medical Center has had discussions about “Patient Navigators.” This appears to be another Crutch Position designed to help patients find their way from one confusing process to another. Many of the Alaska Native regional health care providers are also looking to hire Patient Navigators because of the incredible difficulty their patients have when visiting the Anchorage campus.

Chugachmiut’s response to the necessity for Crutch Positions has been to work on improving patient flow, reduce the complexity of our processes, move towards greater transparency and reduce errors, which improves quality. We analyze process flow, apply lean tools and create a specific action plan for carrying out the improvements that are identified as possible. It has worked for us and for hundreds of other Lean Healthcare providers.

Chugachmiut proposed a patient mapping project to the Rural Anchorage Service Unit tribes a number of months ago. We proposed the mapping of 100 patients through the maze of healthcare at the Anchorage Medical campus. We felt this would give us way more information than the normal Kaizen event would require for an accurate process map. My hope was that the leadership of the Anchorage Medical Campus would then see the parts of the process that could be improved. Simple concept—gather the facts, map the process, create a future state, do the improvement analysis, develop an improvement plan, and execute. PDCA.

The RASU presented the proposal to the Alaska Native Tribal Health Consortium Board a couple of months ago, where it was unanimously approved. That put the project in the hands of ANTHC management.

So what happened with the proposal? From what I have been told, the RASU is too small to map 100 patients because it would take too long. So the leadership is going to map every patient journey in a larger region because they have more referrals to Anchorage. Changes will be made whenever any patient encounters a problem. And the goal is to hire discharge planners in 2011 who will be responsible for coordinating with that large region on a daily basis to determine the number of patients who will be coming to Anchorage, and talk about the ones who will be leaving Anchorage, and coordinating their care. I see CRUTCH written all over this plan.

First of all, individual responses to each defect in a process lead to ever greater variability in that process. Dr. Deming’s famous Red Bead Experiment demonstrates the impact of common and special cause in a process. If the defect is the result of common cause, the only solution is to improve the system. If the defect is the result of a special cause, it will respond to individual treatment.

The patient flow process through the Anchorage Medical Campus is incredibly flawed and wasteful. How do we know that? There is no process improvement system in place. And our rural providers and patients let us know what kind of treatment they receive while in Anchorage. We asked for a patient flow analysis so we could address the flawed process. [I happen to think we have wonderful employees who deserve a well functioning workplace.] What we are getting is something that should have been in place years ago [discharge planning] and Crutch Positions. Lean Managers do not need Crutch Positions.

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