Variation
The first rule of quality is consistency. The antithesis, then, is variation. Noon et. al. write about “The Impact of Variation in the Delivery of Healthcare Services” (publication not available) and note that variation in patient arrival time and variation in treatment time produce long waits and inefficient provider utilization. [Anybody thinking walk-in clinics?] In a comment on the article, Michael Lieb states that such long waits can generate “very negative responses from dissatisfied customers.” Gee whiz! He also comments that with procedures such as mammography, “patient expectations are easily met....” (Where was he when GW needed him.)
In the same journal, Meyers et. al. describe the successful application of Open Access appointments in a military primary care clinic. As they observe, this is counter-intuitive and certainly counter to the triage and wait approach in most ERs today. With this approach, they asked patients, “Do you want an appointment today, and if not, when?” When demand and capacity are balanced, all patients can be given same day appointments, thus eliminating the random arrival of patients. The first paper demonstrated significant improvements in all variables when any variation was reduced.
Ambulatory surgery is an example of predictable arrivals for predictable service and should be intrinsically efficient. The problem comes when hospitals run these centers and mix them with the general OR. The variable of emergency surgery is then allowed to impact an otherwise efficient system.
The take-away message is that efficiency is possible, even with seemingly random systems. All it takes is the will to do it. But that’s also true of so many things in life, like . . . weight loss.
