donderdag 7 april 2011

Lean and caring: Compassion in the valuestream

One of the main pillars of our hospitals' mission is patientcentred care. An impressive campaign and many top-down efforts are being put in place to 'penetrate' workers minds with that thought. How does one apply patientcentred care in a department where we are hard at work applying lean principles, working to increase our effectiveness and efficiency? In an earlier blog I wrote about the theory of the Care compass. But how to turn your theories to a campaign and in practice?
Over the past few weeks I have heard the most heartwarming but also heartbreaking stories from and about patients. About small mistakes with serious consequences. About the difference between the treatment of a case and the handling of a person. Each story with a particular angle or insight. Its own symbolism. As professionals in care we need to hear those stories desperately. Because if we, i.e, talk about the number of additional beddays per year by line infections we are no able to understand what that infection has effectively meant for that patient.We need to untangle those stories from statistics! Stories are needed to get to know the patient behind the numbers and the person behind the case.

A unique "pressure cooker":within a timespan of just a few weeks I was in the opportunity to listen to and sometimes get acquainted with people like Susan Frampton (Planetree), Fred Lee (If Disney Ran Your Hospital), Jan Gunnarson (Hostmanship), E-patient Dave deBronkart, Kathy Torpie (Losing Face), Atul Gawande, Sophie van der Stap (girl with 9 wigs) and Ragna van den Berg (her special TEDxMaastricht video is online). And many others to hear what their personal motivation was to get into care. Experiences from the Eye hospital (Frans Hiddema) where safety is practised in a unique way. How Professor of Pathology Wolter Mooi of VUMC, brings back passion to training doctors. And neurologist professor Bas Bloem (Radboud University Hospital) gets out of his high tower to actually acompany the patient's on his journey. Many of these stories are being put online now. Follow on Twitter @ TedxMaastricht. Many other specific patient stories are also available on the website of the New York Times (Patient voices).

When we no longer see the patient, but only the status, the case and the numbers, not only care for patients gets out of balance but also the care professional him or herself. Doctors and other healthcare professionals grow cynical and resignate. Therefor a number of medical students, together with visionaries from health care (including Radboud REShape & Innovation), launched Compassion for care to bring back passion to care and in the training curriculum.

What can we do in a department where we work on our effectiveness? Where we try to attribute our limited resources as much as possible to treat patients well and promptly. How do we prevent that we, inspired as we are by applying principles from industry, treat patients as if they are on an assembly line? How do we give patients a voice in changing and improving our processes? And most importantly: How can we assess from their perspective what changes are needed not only to deliver an adequate treatment but also a compassionate treatment?
 "As a patient you don't want to go through a process, you want to be part of the process"
To answer that question I have narrowed the issue down. I will not go into the sociological or psychological side of this discussion. I won't talk about culture or leadership (as in an earlier blog). But very practical: is compassion to be found by using exxisting lean instruments?

LEAN and CARE   Lean is more than a toolbox with tools for effectiveness and efficiency. By adopting lean as business strategy  different issues are adressed simultaneously: high quality, low cost and short lead times. Lean is based on ' customer value '. Is the customer willing to pay for the things we do? Translated to care: can we perform good treatment at low cost and quick access. What is  'value' to patients? And what is waste? Compassion is value. Good information and opportunities to make own choices as to the treatment options is of value. By making a tiny adjustment to som eof the lean tolls we can actually start to measure compassion.

When we record our process they ususally seem pretty straightforward. We're seeing a patient at the outpatient clinic, perform several diagnostics. Then therapy and, after checking up at the clinic, dismissal. Through the eyes of the patient it looks quite different though: you are perfectly on time for your appointment at the clinic. Finding room to park your car takes quite a bit longer than expected and, only just in time you het to the central receptiondesk. Unfortunately, there are three others queing up. As asked by the desk clerk you tell him your name, date of birth and the name of your doctor. Despite IT systems several lists have to be consulted. You are told to proceed to KC-3 blue. By now you are ten minutes late for your appointment as you regsiter at yet another desk. Being prompted once again for your name, date of birth and the name of your doctor ….

It's obvious that this description fits the bill better then the process we drew up in our offices. Visualising processes from patients eyes gives as the real information needed to improve. Especially if we add patients emotions to those process steps: confusion, ambiguity in the appointmentletter, stress for parking and waiting at reception. Apart from the emotions for actual therapy/surgery.

One of the tools lean uses to visualize processes is value stream mapping: describing what happens through patients' eyes. By - quite literally - following the patients steps in his journey and capturing that visually (photo/video). From that experience a valuestreammap can be drawn up. For each step (and there are often many dozens to be identified) we can determine whether the patient considers the step to be of value: is he actually willing to pay? Or is it waste? Normally we can then, with a lean perpective, change our processes to eliminate waste and increase value.
 "It is my body, my illness, my treatment"
But: what about compassion? I propose that when we draw up a valuestreammap of a clinical pathway, we do not only at the process but that we also ask patients what emotion they had with each step. And add that emotion to the map.
Result of this should be a map in which not only actual steps are being visualised (and determined whether they are waste or of value) but for each step an emotion is added: waiting, uncertainty, frustration). From that 'photograph' of how our care process really works, we can, together with patients, dream up an ideal process, the way we envision it to be. And then, step-by-step, work to realise such a joint dream. More on that in  a future blog. And also more about a set of criteria by which we pretty quickly assess whether we as a healthcare provider, as a division or as a hospital are actualy working in a patient-centred manner.

Finally: please, sign the charter Compassion for care but start acting as well!

How can we increase compassion throughout hospitals? Over the last few weeks I've found that stories by individual patients actually activated me to change my ways. So I believe those stories should be shared more widely. With some regularity on our Intranet and newsletters employees are asked about the work they do. Just as in the New York Times it seems to me to be of particular importance to hear more from our patients. About their good experiences but also about the lessons we can learn form them as they narrate on the things they've seen on their journeys.

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