The Librarian: Rounding to Be Lean
Lean— “A management system that focusses upon value (from the customer/patient’s point of view) and elimination of waste, making it easy to do the right thing by focusing on improving processes.” (Luca Boi, MHA, University of Utah Health Care Value Engineer.)
Developed by Toyota in the 1900s, Lean was first adopted by manufacturers but is now practiced in many sectors of our society including government, education, service organizations, and healthcare. The University of Utah Health Care is integrating Lean throughout the organization. To build skill levels, staff was invited to submit a problem, learn the process and apply Lean to the problem. Four sessions of “The Physician Leader/Health Sciences Leader: Lean Education Program” were run in 2013. Faculty from Spencer S. Eccles Health Sciences Library participated in three of the sessions working on different projects.
Addressing value and elimination of waste should have a financial impact on the organization. Could Lean be used to determine the financial impact of the librarian on patient care? I submitted a problem to find out. This was a fast track learn and do program that started in September 2013 with training and ended in December 2013 with a presentation on the project.
“The Librarian: Rounding to Be Lean” team started with five collaborators and by the end of the project had grown to seven. The final team included David Alleman, a Lean expert, as coach and the following members:
Abby Adamczyk, Spencer S. Eccles Health Sciences Library Research Librarian
Luca Boi, University of Utah Health System Value Engineer
Kencee Graves, University of Utah School of Medicine Chief Medical Resident
Claire Hamasu, NN/LM MCR Associate Director
Robert Millsap, NN/LM MCR Financial Analyst
Debra Simmons, Utah Diabetes and Endocrinology Center Director of Clinical Affairs
Nathan Wilding, School of Business Six Sigma Green Belt trainee
The problem we identified was that the expertise of librarians is not being used appropriately to inform physicians as they care for patients. Healthcare professionals do not realize that a call to a librarian can be helpful. We assessed that they spend valuable time (3-5 hours/week) trying to find information but do not always get the highest quality or the most relevant information. A 2013 library survey indicated that 50% or more of the faculty who have a clinical role had not used the services of a librarian in the past year. Thirteen percent indicated that they were unaware that librarian services were available. Physicians in the hospital setting may have difficulty finding the answer to a clinical question because there is no recognized process in normal patient care operations to consult with a librarian. This adds to underutilization of librarian expertise.
What We Did
The team decided to use rounding as an intervention. Rounding has been used successfully at many institutions to make health information available at point of need. The Research Librarian was imbedded on four internal medicine rounding teams for 4 morning rounds. A total of 29 questions were asked during the four morning rounds. Search results were returned the same day. The only time this was not possible was the day when 13 questions were asked. While the Research Librarian participated in this project, she continued to fulfill her regular responsibilities of teaching, consulting, and attending meetings. The Research Librarian spent two hours/day rounding and an average of three hours/day searching and distributing the answers she found.
We distributed two surveys: the first to the physicians on the internal medicine rounds with the librarian intervention and the second to physicians on cardiology, hematology, oncology and pulmonary rounds without the librarian. This second group acted as our control group. The first survey gathered information on physician search habits and the use and usefulness of the librarian provided information. The survey of the second group gathered information on their search habits.
We evaluated the quality of the searches by enlisting the trainers from the National Library of Medicine Training Center to review the search strategies and the physicians on our team to review the search results.
Our original intention of assigning a dollar value to the impact of the librarian on patient care was not realized due to the brevity of the project period (2.5 months) and because the data was not available. We discovered, as did other Lean teams, that University of Utah Health Care does not have cost data readily available.
The project ended with all 20+ Lean teams presenting the highlights of what they did and the impact of their project to administration.
Feedback from the participants confirmed the value of the librarian as identified by other value studies. The information provided by the librarian affected knowledge that could be used with current and future patients. The majority of the responding physicians reported that they learned something new or updated their knowledge and that the information gave them more confidence in their decision or action. Forty-three percent said that patient treatment was altered as a result of the librarian provided information and an equal number said that the information provided did not alter patient care. 86% said that there were no adverse events avoided due to the information they received from the librarian. Over half of the respondents said that having the librarian provide the information saved them time. Physicians on the internal medicine rounds spend an average of five hours/week searching for information. The search strategies were rated an average of 9.5 out of 12 points. The quality of the search results was also rated highly with the physicians indicating positive impact on knowledge and patient care.
- Having a librarian on rounds capturing and following up on questions increased the number of clinical questions entering the library system. We increased the number of inquiries to a librarian by 50%.
- Because the librarian, not the physician, took responsibility for finding the evidence to patient care questions; we reduced the time spent by professionals looking for information. This freed them to use that time in other ways.
- Our intent was to determine the dollar value of these impact factors. However, the only dollar value we could determine was for avoided payroll costs due to the time saved for physicians by the librarian providing the answers to the questions generated on rounds. We estimated that a 1.0 FTE rounding librarian would save clinicians five hours of search time/day. This is a conservative estimate based on the amount of time a librarian would take to do the searches. The result is $29,500 – $94,300 net annual savings depending on the salary of the physician.
A subgroup of the team decided to continue exploring how financial impact could be assigned with the information we have. The results of this work will be presented at MLA 2014.
-Claire Hamasu, Associate Director