Using Algorithms to Reduce Waste in the Hospital

The issue of waste is a perennial problem in any organization. Waste is the failure and inability to use something wisely. It is the failure to maximize the potentials and value of a thing or activity.

I have previously written on excessive waiting time,re-work and poor ergonomics as sources of waste. Today, I will identify excessive processing/over-processing as a source of waste. I will also explain the role of algorithms in reducing this waste.

An algorithm is a logical step-by-step procedure for solving problems. When used in healthcare, it helps to set guidelines for critical activities in the hospital.

 Excessive Processing

Excessive processing is like placing a bucket under a running tap to fill it, yet refusing to turn off the tap when the bucket is full. The extra water added and the extra time spent is wasted in the long run. Examples of over processing could be excessive and indiscriminate use of antibiotics, sending patients for laboratory investigations that are irrelevant etc. Consider Jummai’s case:

Jummai is a 5 year old girl who was admitted for anemia secondary to severe malaria. On admission, her PCV was 17%. She was placed on an antimalarial drug and also received a unit of compatible blood. Her PCV rose to 20%. She became clinically stable and was even playing around the pediatric ward. She was scheduled for discharge. But Dr. James who just returned from his annual leave felt that she shouldn’t go home with a PCV of 20%. He decided to transfuse another unit of compatible blood. Unfortunately, she developed a transfusion reaction and spent an additional 6 days in the hospital consuming resources that should have been used on other patients!

We can deduce 3 reasons for excessive processing from Jummai’s story.

• ·        The employee may not really know what the exact standard of his work is going to be. For example, when is the right time to discharge a patient? Sometimes, doctors working in the same facility may disagree on the discharge date for patients under their care.
• ·        The internal standards used to determine quality may not reflect the true patient requirements. From the above case, Jummai’s PCV level alone was not a good indicator to determine her fitness for discharge or continual hospital stay.
• ·        Over processing may be a re-bound effect of rework (re-admission). Dr James may have had a previous experience where he had to re-admit a similar patient after discharge. Therefore to prevent re-work, he may have ended up over-processing.

An algorithm can be used to eliminate over processing. Here’s how it works:

• ·        Set clear standards (for any process) that reflect the actual patient requirement e.g. set parameters that if achieved by the patient will lead to discharge. The setting of standards involves the development of algorithms or protocols for certain situations.
• ·        Involve operational staff, unit leaders and top management in the development of algorithms.
• ·        Review every aspect of your hospital process to identify areas of excessive processing and remove such activities.
• ·        Ensure regular supervision of hospital personnel to ensure that they adhere to the hospital standards of performance.

An example of an algorithm for the management of hepatitis B is shown below.

It may be argued that you cannot have an algorithm for every activity. You should therefore endeavor to have algorithms for critical points of patient management. For example, a hospital that specializes in fertility management may use algorithms to determine the eligibility of patients for certain procedures.

It may also be argued that algorithms can inhibit innovation and creativity. But critics should remember that medicine is a science which is based on verifiable facts. Employees cannot be allowed to base decisions on whims and personal dispositions alone. Allowing this will introduce unnecessary variability to service delivery. Using algorithms thus help to reduce variation and excessive processing.

In developing algorithms or protocols, key players should be involved. The staff that will work with the algorithm should be involved in its formulation. This will ensure acceptance, compliance and successful implementation of the algorithm. Also, contact the national regulatory bodies like the National Center for Disease Control (NCDC) in Nigeria for guidelines on patient management. These guidelines can be adapted to your own hospital.

I will write about ‘Using Checklists to Prevent Medical Errors’ in a future post.