Finding The Patient Who Wasn't Lost
A detailed look at how communication flaws create performance issues and hurt efficiency
Welcome to the Gazebo! Grab a cup and join me for some tips to help you succeed at the intersection of management, communication, and technology.
This Week’s Summary:
New employees are just that – New! They don’t know stuff.
Experienced employees tend to think that others know what they know.
Mistakes can become opportunities for process improvement instead of judgements.
Not adjusting procedures based on past mistakes is a mistake in itself.
If your training and procedures don’t evolve, then don’t be surprised if nothing improves and history repeats itself.
Take a visual journey with me for a moment. Mentally picture the waiting room of the ultrasound department at your local hospital. Can you see it? The rows of chairs? The tables covered by old magazines? The reception desk with the two employees behind the desk answering calls, checking in patients, etc.? Boring music in the background? The slight smell of hand sanitizer? So far so good?
Now picture this same scene in chaos as everyone scampers around looking for a lost patient! The technicians are excitedly talking to the reception personnel who are talking to the doctors. Everyone is stressed out wondering what happened to the next patient who was supposed to be in the waiting room. How did they lose a patient who had already checked in?
Image created Ed Paulson using Copilot in Windows.
The good news is that they didn’t lose the patient. In fact, the patient was in good hands the entire time. The only one who lost the patient was the computer because of a simple personnel training misunderstanding. To the department personnel, the computer is the communication hub through which all information flows and when the computer loses a patient, there is reason for concern.
This scenario is based on something that actually happened to a friend of mine. Bear with me as I spell out some key details related to this scenario that we need to understand the simple source of the chaos and the fix.
The computer showed that a female patient was scheduled to be scanned at 9AM.
It was a double scan meaning that the doctor wanted the patient to receive two different scans during the visit: Let’s say that the first scan was for the liver and the second scan was for the bladder.
A new employee/technician was assigned to do the first liver scan. She assumed that she would also do the second bladder scan given that she was trained to do both scans and already with the patient.
She signed into the computer to do the first liver scan BUT (this is important) she did not, at the same time, enter into the computer that she would also do the second bladder scan. It was obvious to her. She would enter it when she started the second scan.
Another technician checked the computer and saw that there was a patient checked in and waiting for a bladder scan … the second scan our new technician was already planning to perform. There was no computer “flag” related to the first scan already being in-process for the second technician to see so she simply did not know this important reality.
Remember, according to the computer as viewed by the second technician, a patient was scheduled for a bladder scan that had not started. Naturally, the second technician signed in to do the second bladder scan and went looking for the patient, with no luck.
This is when the mild panic set in. The computer showed that the patient had checked in and was waiting to be scanned, but the patient was not in the waiting area. Where was the patient?
After several people, including the supervisor, spent a few stressful minutes anxiously looking for the “lost” patient, they found her safely with the new technician getting her scans.
Initially, everyone breathed a sigh of relief, and then the frustration came out, mostly directed at the new technician. “Why didn’t you tell anyone that you were doing both scans,” sighed the supervisor? “I did,” said the new technician. “I signed her into the computer when I started the scan.” The supervisor shook her head. “You should have signed in for both scans!” “Oh. I didn’t know that. I thought it would be simpler for me to do both scans, so I thought I would finish the first scan and then move onto the second. Sorry!” After a brief pause, the new technician asked, “How was I supposed to know that?” “That is standard procedure here,” answered the supervisor. “Well, I guess I know that now,” replied the new technician with a dejected sigh.
Get the picture? The technician took what she thought were reasonable, efficient actions based on what she knew. What she didn’t know was that her assumptions were incorrect based on the department procedures. Notice the personnel fallout from this simple misunderstanding. The new technician likely feels embarrassed from having caused all of this chaos and may also feel misunderstood and a little defensive. In her mind, she didn’t do anything wrong. She simply didn’t know.
The other department employees, including the supervisor, were frustrated with her because she did not deliver as she “should have.” They may have left this experience with the first nagging question about whether this new employee can be trusted. Filtering and confirmation bias, if not held in check, might unfortunately begin to reinforce this belief.1
This simple mix-up presents an excellent example of how simple things can cause misunderstandings, and also offers a clue about the actions you can take to avoid them in the future.
“But there is no way we can anticipate all of the things that can happen in the future,” said my friend when I asked what they plan to do to avoid this in future. True!
No matter how much we try to anticipate all that can happen, life has a way of reminding us that we are not omniscient, and we should plan for the unexpected. This is where continual process improvement comes into the picture.2
Continual process improvement happens when an organization treats its current state as just that, its current state. When the unexpected occurs, the procedures that dealt with the unexpected event should be updated to include the new learning. In essence, the learning from the prior unexpected event becomes embedded in the organizational knowledge base so that it becomes part of a “new” current state.
A key issue here is that the previous New Technician Training did not specifically include this “double scan” login procedure. If it had, then the likelihood of this misunderstanding would have been reduced. When events like this missing “double scan” procedure come up it needs to become part of the organizational culture by modifying the training so that new hires get this information.
Instead, what typically happens is that after the event occurs and the new technician is made aware of the “double login” procedure, everyone goes back to work, and it is business as usual. Business as usual, that is, until the next new person comes along and gets a double scan and chaos once again erupts.
Don’t think of your training procedures as static. Instead, think of them as continually evolving. This way you will always be incorporating new learning into your organizational knowledgebase while also making your business more resilient.
Technology can also play an important role here. For a situation such as this, computers are great at recognizing and remembering obscure combinations of events that we humans might gloss over. For example, a popup could be added to the double scan login screen that reminds that technician to sign in for both scans at the same time. Problem solved!
My brokerage house does something like this when I place a trade. It will remind me that this particular trade will take specific actions based on specific circumstances, and then ask me to confirm that this is my intention. This type of check may seem like a nuisance sometimes, but in actuality, I appreciate the quality check and occasionally will rethink the way I have set up the trade based on the computer’s nudge.
Why don’t folks naturally think this way? It may be that we have a tendency to focus on what is in front of us and not really give much weight to what we cannot see affecting us in the immediate future. We may intuitively expect that the current group of technicians is the group we will have forever, which is clearly not accurate, especially for a larger organization like a hospital with a larger staff.
Folks leave. Departments grow. Each of these will prompt hiring of new employees who will need to know about this special “double scan” procedure and if they are not trained in it, then nobody should be surprised or disappointed if confusion happens in the future.
Have a great week and thanks for stopping by! ☮
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Getting Through: A Systematic Approach To Being Understood (ISBN: 9798987950807)
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Take a look at my post from June 10, 2024 for how this same type of scenario had similar affects for a floral shop delivery driver.
Your point is so valid, Ed. I think we will see even more chaos in the future work place as more dependency and credibility is given to computers and less to the human element. There always has been a window period when new employees learn and develop mastery of their job skills. When the workplace is fast paced and lacks a proper training program it invites errors and a lower level of productivity. Everyone makes mistakes, and errors in the workplace are costly.