Eben Kermit: ‘Process Improvement’ from the Other Side of the Bed

I am an engineer. By definition, I use the engineer’s “tool box” of observation, data, didactic reasoning, hypothesis, and testing to solve problems. One subset of these is “process improvement.” There are many popular and traditional methods including Six Sigma, Pareto charts, and Fish Bones. In addition, there are other metrics such as Net Promoter Score and Satisfaction Surveys that attempt to quantify the customer experience. Recently, I had an opportunity to use my first-hand observations and analytical training to assess my experience from an unfamiliar vantage point—that of a patient.

It was the start of a three-day holiday weekend. I was spending time celebrating a milestone birthday for a family member. It was sunny and an unseasonably warm day. We shared stories and reminisces over good food and beverages. Life was good. I said my goodbyes and headed for home. During the hour-long drive, I felt abdominal discomfort that started to escalate. By the time I arrived, I was in severe pain and could barely walk. I curled up in fetal position, hoping the symptoms would subside. I am a stoic and often will “tough it out” before seeking medical attention. I announced to my wife that this was different: “I need to go to urgent care—now!”

Process Improvement: Don’ t fall ill if you have any control of the situation.

Upon arrival at the clinic, I was told that they were not staffed to help me and was redirected to the emergency department (ED). The waiting room was full. After years of working in healthcare as a biomed, I’m familiar with the environment, culture, and procedures. But I was unprepared for what was about to unfold. I was about to go through the classic steps: present with symptoms, get diagnostic data, receive a diagnosis, and then be admitted as an inpatient for treatment. I’ve experienced this just once before, when I was six years old and having my tonsils removed.

Process Improvement: Learn from life’s experiences.

I was lead back to an exam room for medical staff to take vital signs, collect bloodwork, and perform a physical exam. What I didn’t expect was the slow pace. After a couple of hours, the ED physician let me know that I was running a fever and my white blood cell count was elevated, but they didn’t know the root cause. My abdomen was swollen and tender. The next station on my journey was a trip to the CT scanner, again a first for me. Again a delay until I was rolled down the hall. Once the scan was complete, there was another delay the on-call radiologist. Other patients were on a higher priority in the queue due to trauma or auto accidents. I was reminded that patience is a virtue, but it’s really hard to be patient when you are not feeling well.

Process Improvement:  Prepare for the worst, but expect the best. Keeping a positive outlook (both staff and the patient) is helpful. Handoffs are the most likely times for mistakes.

After a while, the ED physician said she had “good news” and “bad news” to share with me. The “good news” was there was a diagnosis. The “bad news” was I would be admitted to hospital as an inpatient. They knew the source of the infection and inflammation and I would require IV antibiotics. The IV was started and the journey continued.

After a time, I was introduced to the next shift and a new ED doctor who reviewed the medical history and reassessed the present medical conditions. Another wait interval followed. Next, I was visited by the on-call colorectal surgery resident, who explained the treatment plan and would contact bed control for admission. Two hours later, I was still waiting for transport. I do not make a good patient— I’m feisty and don’t like to wait. I asked about the room and was told I was “first in queue.” Nothing was happening. I asked the E.D. staff if they could wheel my exam bed themselves—request denied. “Wait for bed control and transport” I was told.

Not satisfied with the lack of progress, I called transport on my cell phone directly. I was told that I was third in line, but they were short staffed and I’d be taken as soon as they could get to me.” My confidence was rattled and I’d have to continue waiting.

Process Improvement: Give realistic estimates. It is better to over deliver and under promise, than the reverse. If it is a holiday weekend with prior trend knowledge, increase on-duty staff.

After nine hours in the ED, a gregarious man showed up with a “rolling chair.” I gathered my belongings and was wheeled to the third floor. I was met by a nurse and began my stay as an inpatient. My expectation was an overnight stay or perhaps a second day, once the antibiotics started to take effect. My estimate proved to be completely, totally, and utterly short of what would actually transpire. I’ll tell you all about that in my next post.

Eben Kermit is a biomedical engineering supervisor at Stanford Health Care in Palo Alto, CA.

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