Addressing Problems in Medical Practice Operations

Last Friday a man jumped the White House perimeter fence, ran across the front lawn, opened the front door and almost entered the White House. The Obama's were not in residence; no one was hurt and the intruder was quickly apprehended.  Early suggestions to prevent a recurrence included barring pedestrians from the sidewalks around the White House, and implementing a security zone where all bags would be searched.

The response is typical: Add another layer of complexity. That makes sense if the current security system isinadequate. If the problem is one of execution, more complexity adds costs and aggravation without addressing the root cause of the failure.

This breach of White House security and the early potential responses can be instructive for physicians and administrators who are regularly called upon to address service failures. One way of identifying the root cause of a breakdown is an approximation of the iterative questioning technique called the "5 Whys." To illustrate:

Problem: An intruder penetrated the grounds and almost entered the White House.

Why #1: How did he open the door?

It was unlocked.

Why #2: Was there a guard at the door?

No.

Why #3: How did he get to the front door?

He ran across the lawn.

Why #4: How did he get on the lawn?

He jumped the fence.

Why #5: Why didn't the handlers of the attack dogs react to the fence alarm?

The intruder did not have a backpack or an obvious weapon.

They were afraid of the adverse effects of cell phone video showing White House dogs attacking a mentally ill person.

Why #6: What is the function of the White House security detail?

To protect the president and his family.

The example illustrates several nuances:

• The five questions do not all need to begin with "why."

• More than five questions is OK. (Less than five is probably too few.)

• The questions tend to progress in a linear fashion, but not necessarily.

• The exercise may identify multiple failures.

• The root problems are generally those of process or execution.

Based upon this analysis, these solutions are obvious:

• Have a guard stationed on the front porch any time the front door is unlocked.

• Retrain the dog handlers on their primary responsibility.

• Consider replacing or augmenting the attack dogs with dogs that can contain an intruder without mauling him.

None of these solutions require inconveniencing Washingtonians or tourists, and only the possible solution of additional or different dogs has any additional cost.

All physician practices are overloaded with both work and labor costs. How many of the processes you have in place were implemented in response to a single service failure? How many of them could be eliminated if the purpose of the process was well understood and a simpler process was faithfully followed?

It is my experience that most practices have enough staff to do the work that needs to be done. They do not have the staff to do the same work two to three times because the process is not reliable, and they do not have the staff to correct the inevitable errors when processes are redundant and convoluted.