Process improvement
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| The management directive is simple: Cut waste, make work easier and simplify systems. Pioneered by Japanese automaker Toyota 50 years ago, the approach is known as "lean management." It involves large doses of observing, measuring and creative problem solving. Large businesses such as Boeing have painstakingly followed the tenets of lean management and reaped major savings. Now, some hospitals and other health facilities are going lean as well. They've experienced successful results and here's how they did it. |
Because keeping track of equipment is a constant headache, some hospitals have invested $1 million or more in complex software to find errant pieces of equipment so that someone can fetch them.
But what if a hospital found a simpler way of handling equipment that made these expensive and time-consuming steps unnecessary?
Four years ago, this type of creative thinking occurred to Allen Caudle, vice president for supply chain management at Swedish Medical Center, Seattle, a 1,296-bed system with three acute care facilities.
With Microsoft Corp. based nearby, Seattle is to some degree a bastion of high-tech. Caudle was prepared to join the high-tech trend by tracking hospital equipment. He was planning to purchase a system that required installing signaling devices all over the hospital.
Then he discovered "lean thinking," a decidedly low-tech approach developed by Toyota Motor Corp. in Japan a half century ago. It had already been adopted by Boeing Corp. for its nearby airplane plants and was just starting to make the leap into health care.
Caudle dropped plans for the tracking system, adopted the lean system and told staffers to fan out with stopwatches and paper and pencils to closely observe employees as they did their jobs.
Somewhat like ornithologists painstakingly tracking a flock of rare birds, staffers marked each employee's movements by looping lines on a paper diagram of the workplace, called a spaghetti chart.
Then, in five-day workshops, also known as kaizen events, management and front-line workers debated ways to reduce the size and number of those loops and create a more efficient process.
The workshops came up with some disarmingly simple changes that have profoundly improved efficiency, quality and employee morale at the hospital.
A key principle of lean management is to reduce waste and make work simpler. That's a big change for hospitals, where systems seem to be getting more complex.
At Swedish, for example, intravenous pumps were constantly being misplaced on their journey from a patient's bedside to sterile processing and back again.
The Swedish workshop studying I.V. pump processes decided it would take considerably less work to leave the pumps in patient rooms. But who would clean them? Environmental services workers are there every day to make the bed-- could they do it? No one had ever proposed such an idea, and it seemed absurd at first, but no one could come up with a good reason not to do it.
Environmental services workers were trained to clean the pumps and they began performing new duties.
As a result, cleaning costs fell from $12.65 per pump to 65 cents and the turnaround time for cleaning the pumps went from 21 hours to 34 minutes.
Caudle calls such solutions "brains before bucks." He and his staff insist they are not antitechnology, pointing out that Swedish actually uses some high-tech tracking devices, such as point-of-use cabinets and bar code scanners. But before implementing automation, they used lean thinking to fix basic processes.
"If you automate a broken process," Caudle says, "you make mistakes at the speed of light."
Caudle and his employees also set
to work on another frustrating issue--slow delivery and low accuracy
of surgical case carts, a problem that directly affects the quality
and efficiency of the surgery department.
It was a high priority for Swedish because of patient safety and because surgery is a chief money-maker.
Again, staff closely tracked workers building the carts and brought their charts to the kaizen event, where intense discussion yielded some dramatic solutions.
In the cart-assembly area, storage areas for frequently used pieces were brought closer together.
The average time it took to build a case cart fell from 86 minutes to less than 15 minutes, and the accuracy of the contents of the case carts improved.
The shortened time allowed materials management to move from batching orders the night before, as most materials management departments do, to assembling each case cart "just in time" for use, which is a key lean concept.
Materials management can then build carts for last-minute cases and not build them for canceled cases, making the operation even more efficient.
The principle of the matter
Using lean principles, Toyota manufactured cars with half the human effort, half the manufacturing space and half the capital investment that other car manufacturers used.
Lean has since become a mantra of American industry, including such giants as General Motors and Dell Computer Corp.
In the past few years, partly due to the urging of manufacturing executives on their boards, a handful of hospitals across the country have adopted lean thinking.
Caudle says some people don't see a connection between manufacturing and health care, but he says, "The fact is we're a manufacturing facility. The same processes are involved. We process raw materials, and the assembly line is the surgery suite."
Cindy Jimmerson, R.N., a lean health care consultant based in Bonner, Mont., argues that lean is exactly what hospitals need right now. Some facilities in her state are at the brink of closing because they are inefficient, but she says, "If you could reduce the waste, these hospitals would be fine."
Jimmerson says the process also reduces errors by simplifying and standardizing complex hospital management systems. And, she says, it improves employee satisfaction by giving them new processes that are less frustrating.
Saint Mary's Hospital, a 324-bed hospital in Grand Rapids, Mich., just finished using lean to improve the processing of sterile surgical instruments.
John Collins, M.D., vice president for quality at the hospital, says front-line employees play a direct role in creating improved work patterns. The employees get very engaged, he says. "They go back to their work and become advocates of the new process."
"Lean thinking incorporates a principle of visualizing your work," says Sandra Rose, R.N., the lean facilitator at Saint Mary's. Rose and others closely observed the surgical supply process, from central sterile and materials management to the OR.
Then, as the lean process requires, the information was brought to an intensive three-day workshop composed of directors and front-line employees from affected areas. The group asked tough questions in an attempt to break through conventional ways of thinking and create a dramatically simpler way of doing things.
They noted that when OR staff needed an extra item, such as a scalpel, someone had to go to a supply room on a different floor or call central sterilization. Sometimes several CS workers were called before the item arrived in the OR.
To remove these bottlenecks, the workshop decided to set up shelves outside the OR stocked with typically needed items, which has reduced calls to central services. It also allowed just one or two phone numbers for surgery to call when someone has a request, so that several workers don't waste time doing the same task.
Within two weeks of making the changes, surgery reported that it had all the items it needed. Surgical volume increased--then accuracy plummeted.
The cause was that central sterile employees "fell back to their old ways under the increased pressure," Rose says. The team regrouped to again improve accuracy. Lean experts often point out that the process is an ongoing, unending effort.
Success comes in all sizes
Medium-sized hospitals also are applying lean thinking. Jimmerson says she helped Community Medical Center, a 135-bed hospital in Missoula, Mont., convert to lean throughout the organization.
One project involved rethinking supply rooms in the hospital's 48-bed med-surg unit. Community made the location and stock of materials match the work. As a result, it reduced the value of the stock by $7,900 and the unit's calls to materials management for more supplies from 32 a day to two a week.
Because lean is so simple and low-tech, having a three- to five-day kaizen event isn't essential, says Jimmerson. This is especially helpful for small hospitals that have limited personnel, especially in nursing where staff can't afford to be away from work for long.
Scott Decker, vice president of quality at Appleton, Wis.-based ThedaCare Hospitals, a three-hospital system, reports that the organization used lean throughout the organization, including to reduce supplies in its ORs and cath labs.
Using one common lean approach, easy-to-identify colors were pasted on shelves, appearing as more articles were removed. Green appeared first, denoting a sufficient supply; then yellow, meaning it was time reorder; and finally red, implying there was a shortage of that item.
Decker says ThedaCare saved $7 million dollars on all lean projects last year, with one-half million of that total in supplies. Lean also helped the organization to reduce the work force by 80 FTEs through work redesigns without layoffs.
Larger hospitals are also moving ahead with the new approach. In Seattle, Virginia Mason Medical Center, a 336-bed hospital, was an early adopter of lean thinking in health care.
Several years ago, CEO Gary S. Kaplan sent top executives to Japan to study the Toyota system first-hand. Among other things, John Donnelly, administrative director of supply chain at Virginia Mason, says he used the lean process to move from batching case carts to just-in-time delivery to change the location of supplies and to avoid duplication. As a result of all its lean activities, Virginia Mason reports that it saved $6 million in planned capital investment, freed 13,000 square feet of space, cut inventory costs by $360,000, reduced staff walking by 34 miles a day and improved patient satisfaction.
What a concept
John E. Siedlinski, a materials management consultant based in Naperville, Ill., says hospitals have been using similar strategies for years.
"Lean management is a good concept, whatever name is applied to it, but it is not new," he says. "In the 1980s we called it productivity improvement. The idea was that you either moved the work or moved the workers. With lean management, you quantify the movement in more detail, but you don't necessarily need the detail to understand what needs to be changed. Lean management serves to quantify what your gut already tells you makes perfect sense."
Lean specialists, however, disagree. Matt Morissette, a lean health care consultant based in Mont Vernon, N.H., says lean is both simpler and more comprehensive than other methods used today.
He says the balanced scorecard comes with no tools to correct the problems it identifies.
While Six Sigma is a highly statistical approach, it isn't easily adaptable to health care front-line employees--but it can be used in combination with lean.
Jerry Balzer, operations manager for logistics at Swedish Medical Center, says several aspects of lean thinking are unique, such as going on-site, looking closely at the workflow and documenting it.
He adds that lean management follows up on changes to make sure they are still working.
Tom Moench, a former lean advisor at Boeing who helped establish the system at Swedish, says lean also pushes hard for change. In a kaizen event, "someone says, 'We can't do that,' and then they work through it," he says. "The process gives them tools to go beyond what they think is possible."
Ken Fortune, director of logistics at Swedish, says discussions in the kaizen events, though sometimes heated, help build lasting ties between such departments as central sterilization and surgery, where lack of communication can be a key factor in wasteful processes.
"There is a true sense of 'team' and an understanding of people's roles," Fortune says, adding that the process is blame-free. "It's very easy to step back and blame someone because the case cart wasn't ready on time," he says. Instead, he adds, people have learned that "everybody is working very hard at what they do. It just may not be efficient."
Moench adds that changes made at the workshops can be applied immediately and have immediate results. "Every project I did," he says, "was dramatic and magical."
Leigh Paige is a freelance writer based in Oak Park, Illinois.
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