This is part of an ongoing series of audio profiles of front-line improvers.
April 2008
Jody Crane, MD, MBA
Board Certified Emergency Physician
Mary Washington Hospital
My name’s Jody Crane. I’m primarily an ED [emergency department] physician. I manage our “20-doc” ED group half-time and I work clinically half-time at Mary Washington Hospital in Fredericksburg, Virginia. We’re a not-for-profit, 417-bed facility, kind of in the middle of nowhere. The next closest hospital is 40 miles in any direction. Our ED is the second busiest in the state. We’re going to see 100,000 patients this year. I’m also an adjunct professor at the University of Tennessee Center for Executive Education. I teach physician-led operations and I teach lean health care.
When I was training I just thought I’d be a doc somewhere and have a nice four-on, four-off lifestyle for the rest of my life and kick back. You go back to like, 2002/2003 in our hospital. We had just opened a brand-new 50-bed emergency department and we were seeing about 78,000 patients at that time. And we had really, really bad processes and long waits. In 2003 we kind of got jammed up with beds on the inpatient side so we had lots of holds. We averaged for a four-month period 20 holds on average in the ED at a time. So, half of our beds were taken up with holds.
And it was December 2, 2003. I’ll never forget that day as long as I live because there were 44 holds in a 50-bed ED at noon, and there were 75 patients in the waiting room. And we literally had six providers on to staff six beds, and patients were furious. And everyone that came through the door said, “You need more docs.” And it just sort of highlighted the overall frustration and lack of understanding from a layperson’s perspective about what the true issues were. I actually considered changing jobs many times.
I decided I could either live with it, fix it, or I could get out. And I actually went back and went to MBA school thinking I was probably going to transition out of medicine, and I sort of found a niche in health care operations there. That caused me to look at things in a new light in terms of, yeah, maybe there are a lot of problems that could be solved instead of just running away from them. I went back to my facility, started fixing some things. Health care workers are great at working around day-to-day problems and coming back and doing it all over again. So you have a lot of day-to-day heroes. And so initially I was kind of the lone gun that said, “Hey, man, there’s a better way.” And slowly but surely people sort of tracked on.
I learned some formal change management techniques and true operational improvement tools like queuing and theory of constraints and that sort of thing. And to top all that off, lean. When I started getting into lean is when it really opened my eyes because it forces your focus on the patient’s perspective and eliminating waste. And a lot of those other tools don’t focus you there. I always think there’s a better way to [do] everything. If we don’t know about the better way, it’s because we don’t know about the technology or the ideas that can create the better way.
I tell you now, after implementing several really unique process improvement efforts and implementing lean concepts, we’re at the point where we have visitors every couple weeks from all over the US who come and look at our ED. We’ve had JCAHO [The Joint Commission] investigators say it’s the best ED they’ve ever seen out of six or seven hundred.
From a care perspective, we’re really able to provide exactly the care that the patients need. So if you come to our ED and you don’t need anything, very low-resource utilizer, chances are you’ll be in and out, definitely in under an hour, but on average in 35 minutes. And if you need low resources but not zero — actually with all of our treat-and-release patients — our average length of stay is under three hours.
Right now we have three teams of probably 15 staff members separately working on problems and processes. And we’ve got this organization that’s now bought into the continuous change and continuous improvement. And for lots of health care organizations, especially lots of EDs, that’s very, very difficult.
So, you have to have a lot of patience. You have to be process oriented and at least a little bit mathematically and data inclined. But most importantly, you have to be really compulsive; you have to be a really good leader and not the kind of leader that tells everyone what to do, but the leader that listens, gains consensus, and realizes that change is a gradual process of increasing buy-in and not a sort of a top-down thing.
Early on I used to lead change efforts by saying, “Dr. Crane has a plan. Here it is. Let’s do it.” The most successful project I’ve ever had, which is this new project that we’ve been working on for the last year called “rapid assessment triage and efficient disposition” — which is essentially guaranteeing that every patient’s seen the minute they walk in the door — that project was actually completely developed by staff. And so I completely changed my role and acted as a facilitator and, knowing lean concepts and lean tools, was able to say, “Okay, here are the two problems we’re going to solve. You guys figure out how to solve them,” with a little bit of gentle guidance. And it was really, really amazing. We had a team of probably 20 people, and they developed an entirely different new process. In the olden days, it would have been Dr. Crane going, “Here’s our new process. We’re going to try it and I’m going to watch over it all day, every day, until you get it right.” The amazing thing about this new project, which is the most successful one we’ve ever had, is that I wasn’t even in town when they did it on the first day. And everybody knew their roles; everybody knew what they were supposed to do. And because they had all developed it, it was a smash hit on day one. They own the process now and they’re sort of on autopilot in terms of continuous improvement. So I think that’s what it’s all about.
