Sub-optimizing the Paging System

There are so many challenges in healthcare needing immediate attention that it can be overwhelming to know where even to start. What frequently happens is that a particular department or division will take it upon themselves to make an improvement that benefits their area, without recognizing the impact that this change has on a broader scale. When an improvement occurs that benefits one area to the detriment of “outside” process participants, this is called sub-optimization. Sub-optimization looks great as a formal process but in the informal process (i.e. the way it plays out in the front line of care) it quickly becomes unmasked. Not only does sub-optimization make the overall process worse but it also creates an immediate work-around. Here’s an example:

A large healthcare network reached a point in its growth where the computer-enabled paging system could no longer accommodate abbreviated callback numbers with only five digits. The decision was made to make a change in the system that would require users to enter the full ten-digit number into the callback field. Advanced warning of the change was made by email and on e-bulletins several weeks in advance to launch so that care providers wouldn’t be caught by surprise. So here’s the formal improvement:

1. Care provider goes onto the computer to page someone
2. On the paging screen, they enter the ten digit callback number
3. The person paged calls back using the ten-digit callback number
4. Communication as before!

Easy, straightforward and user-friendly, right?

Here’s how the launch went: When the new system was activated, frontline care providers quickly realized that they could no longer enter callback numbers to a significant number of phones because they didn’t have ten digit numbers! It turned out that in at least one of the network hospitals about one third of the phones are on internal phone lines with only five digits. Further, many of these phones are the ones that are next to the computers from which pages are sent and many are located in patient care areas where emergency contact may be critical.

Fortunately, frontline care providers are accustomed to “improvements” made without their input and quickly devised a work-around (informal process). The paging system is alpha-text capable, so almost immediately people started to write the five digit number in the text box, leaving the “improved” number entry blank. Of course, now everyone is largely ignoring the “improved” number entry site for all of the numbers, and they continue to abbreviate all numbers into five digits as before.

Sub-optimization occurred, at least in part, because the changes to the paging process were made without vital input from frontline caregivers who use the system every day. Without their input, the paging process was not visible in its entirety and the correction made was only from the vantage point of the IS/Communications department. The new and “improved” system is now worse than it was before. Not only has inconvenience been systematized, but it has also introduced an element of risk into the paging process for patients and staff when critical calls need to be made. Frontline care providers recognized this immediately and made the necessary work-around. Of course this work-around is also sub-optimal because it reinforces the likelihood that the wrong number will be called at another hospital (remember the initial reason for doing this change?)

So in the end, a lot of effort and resources went into what is now a suboptimal change because the right people weren’t at the table. It always takes far more effort to fix sub-optimization - it doesn't take long at all for the work-around to become very comfortable! I wonder if IS/Communications is even aware that a work-around is in place.