Recently my 93-year-old mother was briefly hospitalized for gastric distress.  This happened while I was on the road serving clients but I hurried to check on her as soon as possible.  My mother has advanced dementia so it was to my 95-year-old father that I directed my questions.  I asked how my mother was settling back in at home and if there were lingering issues.  “Fine” and “no” were his responses.  Then I asked to see the discharge paperwork my mother brought home with her.

leanhealthcare_dischargewasteHere’s the rundown of what she received:

  • Page 1-2: Information on the importance of smoking cessation (She has never had so much as a puff of a cigarette in her 93 years and there has never been a smoker in the household with her.)
  • Page 3-4: How to manage heart failure (She does not have and never has had heart failure.)
  • Page 5: The importance of immunizations (Hers are current.)
  • Page 6-7: Checklist for diabetes care (She does not have diabetes.)
  • Pages 8-10: Wound care (She does not have wounds)
  • Page 11: Medication reconciliation form with a medication discontinued over a year ago on the form as a current med

There was nothing in the packet that related to her diagnosis.  There were no specific discharge instructions.  There was not a hint that she needed to follow up with her doctor.

As one who spends my professional life working with healthcare providers, I knew exactly what was going on.  As for page 11, my mother’s current medications are all documented in her primary care provider’s electronic health record but the hospital didn’t have access to that.  Instead they relied on the memory of a distraught elderly and hearing-impaired spouse to complete the med rec.  I don’t excuse it but I understand how the error happened.  For now I will take a big breath and look forward to the day when information systems can talk across the corporate divide so that care can be improved.  Interoperability and collaborative mindsets cannot come too quickly.

Pages 1-10 are a bit more troubling to me.  In order to NOT MISS educating any patient with common chronic illnesses such as heart failure, diabetes, or pneumonia, the hospital created a standard generic discharge packet that included information for ALL of those diagnoses.  In a sense the hospital said, “By golly, we know how to make sure everyone who needs any of this education gets it.  We will give it all to everyone whether they need it or not!”  The hospital probably saw this action as mistake-proofing but in reality their CYI approach – the “cover your illness” healthcare version of CYA –introduced waste and the opportunity for other kinds of mistakes.  They had not mistake-proofed.  They had mistake-generated.

The patient/customer needs only the information that pertains to his or her diagnosis and condition.  To give unrelated information is to introduce complexity and confusion for the patient and the patient’s family.  To sort through recommendations that are totally unrelated to the patient’s situation can lead to what the hospital might call non-compliance but I would call plain old confusion, which is a form of waste.  How can the patient comply when the patient can’t even figure out what is relevant and what is not?

Why would the hospital knowingly create this wasteful and error-prone documentation?  I believe they did this because they saw the problem of discharge education as one of internal compliance.   They lost sight of the face and the voice of the customer.  They forgot to ask, “What does the customer need?   How can we reduce errors and waste for the customer?”

For lean efforts to improve value and decrease waste, the customer must always be top of mind and the center of our universe.


Blair Nickle, Senior Manager for Lean Healthcare and Process Improvement at HPPToday’s blog was written by Blair Nickle, executive director at HPP.

For more than 25 years, Blair has dedicated her career to the improvement of processes, quality, safety, patient satisfaction, employee engagement, physician satisfaction, and financial vitality in healthcare organizations.  Her content areas of expertise include instructional design, performance measurement and improvement methodologies, information systems implementation, strategic planning and deployment, project management, and human resource development.

Blair holds Master of Business Administration and  Master of Science in Library and Information Science degrees from the University of Tennessee.  Her undergraduate work was performed at Emory & Henry College.

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