Learn­ing to be Lean

One hos­pi­tal’s staff dis­cov­ers im­prov­ing ef­fi­ciency isn’t easy

Modern Healthcare - - NEWS - BY SABRIYA RICE


ON A WED­NES­DAY MORN­ING early last month, a dozen nurses, house­keep­ers, sur­gi­cal tech­ni­cians and sur­gi­cal as­sis­tants at Pres­ence Health’s Sts. Mary and El­iz­a­beth Med­i­cal Cen­ter are run­ning be­hind in their hunt for ways to save time on the hos­pi­tal’s busy sur­gi­cal floor.

While other staffers per­formed their usual du­ties, the group, meet­ing in a con­fer­ence room with a wall full of brightly col­ored Post-it notes, is mid­way through the chal­lenge handed them by the hos­pi­tal’s lead­ers. They are spend­ing a full week ob­serv­ing their col­leagues’ ac­tions be­tween surg­eries to iden­tify in­ef­fi­cien­cies and de­vise a stream­lined work­flow.

On this third day, Maria Vela, peer­ing at the wall with one hand on her hip and the other on her chin, sug­gests sur­gi­cal tech­ni­cians like her be given the task of cart­ing new pa­tients into the op­er­at­ing room. Nurses, who usu­ally per­form this task, are too busy en­ter­ing pa­tient in­for­ma­tion into the elec­tronic health-record sys­tem and grab­bing sup­plies to re­stock the rooms, she says.

“They would refuse, even in an experiment,” im­me­di­ately coun­ters Jackie Kostakes, the nurse on the team. Nurses need to ver­ify pa­tients’ iden­ti­ties, a key part of main­tain­ing pa­tient safety, she ar­gues.

At the be­gin­ning of the week, the peo­ple in the room barely knew each other. Some had never talked about their tasks. Now they are try­ing to fig­ure out how to re­duce op­er­at­ing room turn­around times on the eight-suite surgery floor—from an av­er­age of 30.55 min­utes to 25 min­utes.

Paresh Parikh, a sur­gi­cal as­sis­tant, throws more cold wa­ter on Vela’s sug­ges­tion. The sur­geon needs to talk with the pa­tients first to en­sure the cor­rect body part is marked for the surgery, he says. “It wouldn’t work.”

The ten­sion in the room mounts. The team needs to gen­er­ate a fi­nal list of so­lu­tions by the end of the day. Ev­ery pro­posal seems flawed.


The tac­tic be­ing used at Pres­ence— where front-line work­ers spend a week ex­per­i­ment­ing with ways to im­prove a pro­duc­tion process—is known as a break­through rapid im­prove­ment event. It’s part of the Lean qual­ity im­prove­ment method now in use at a num­ber of hos­pi­tal sys­tems across the U.S.

San­dra Bruce, CEO of Pres­ence Health, launched the 11-hos­pi­tal sys­tem’s Lean ini­tia­tive in 2012 to boost em­ployee en­gage­ment and slash in­ef­fi­cien­cies that hin-

dered the de­liv­ery of high-value care. The OR turn­around time ini­tia­tive is this par­tic­u­lar hos­pi­tal’s sev­enth rapid im­prove­ment event aimed at pe­ri­op­er­a­tive ser­vices. Pre­vi­ous events cov­ered in­pa­tient pre­pared­ness for surgery and com­plet­ing check­lists be­fore pa­tients reach the hold­ing area.

Over the course of the rapid im­prove­ment week, which was ob­served by a Mod­ern Healthcare re­porter, the dis­cus­sions among team mem­bers be­come more can­did. Com­plaints are aired about less pro­duc­tive staffers, older work­ers sup­pos­edly be­ing less pro­fi­cient work­ing with EHRs, and man­age­ment not spell­ing out clear job roles.

Each prob­lem is writ­ten on a Post-it note and stuck to the wall of the war room, where team mem­bers gather be­tween each day’s work-site in­spec­tions. “We’re go­ing to need a lot more Post-its,” jokes Marge Welchans, as she searches for an empty spot on a wall. Welchans, who works as a fa­cil­i­ta­tor at Pres­ence Health’s United Sa­mar­i­tans Med­i­cal Cen­ter in Danville, Ill., is what the Lean team calls the “out­side eyes”—a staffer from another depart­ment.

The im­passe be­tween Vela and her co-work­ers is not un­com­mon dur­ing Lean process im­prove­ment work. Over the course of the week, team mem­bers try some things that work and oth­ers that don’t. They keep tin­ker­ing, hop­ing to mud­dle their way to a more ef­fi­cient way to han­dle pa­tients, pro­vide treat­ment and man­age sup­plies. While they will have an op­por­tu­nity to re­visit and re­fine those pro­cesses in the fol­low­ing months, the stream­lined pro­cesses are slated to be­gin the fol­low­ing Mon­day.

Through­out the week, Lean team fa­cil­i­ta­tor Ron­ald Guidzi, a for­mer nurse who now works as one of 35 “break­through im­prove­ment” fa­cil­i­ta­tors em­ployed at Pres­ence hos­pi­tals, stresses that it’s all up to the team mem­bers. “We de­sign the new world,” he tells them in a mes­sage that’s both en­cour­ag­ing and in­tim­i­dat­ing.


Bay­lor Scott & White Health, Den­ver Health, Vir­ginia Ma­son Med­i­cal Cen­ter, ThedaCare, Group Health Co­op­er­a­tive, Seat­tle Chil­dren’s Hos­pi­tal, Mas­sachusetts Gen­eral Hos­pi­tal and Emory Healthcare are among the health sys­tems that have adopted Lean meth­ods to re­design clin­i­cal and busi­ness pro­cesses. The im­prove­ments de­vel­oped by Lean teams gen­er­ally aim to cre­ate stan­dard­ized pro­to­cols, cut waste and de­velop cul­tures of con­tin­u­ous im­prove­ment that al­low hos­pi­tals to adapt to rapid changes in the healthcare sys­tem.

But de­spite proven re­sults, a lim­ited num­ber of health sys­tems are us­ing the Lean method. It re­quires the com­mit­ment of time and re­sources. It also can be dif­fi­cult to get some hos­pi­tal and physi­cian lead­ers to em­brace the Lean ap­proach, which re­lies on en­gag­ing lower-sta­tus front­line staff in prob­lem solv­ing.

“The way they have done busi­ness for their en­tire ca­reer is turned com­pletely up­side down,” says Dr. John Tous­saint, who in­tro­duced Lean prin­ci­ples when he served as CEO of Ap­ple­ton, Wis.-based ThedaCare from 2000 to 2008. He later launched the ThedaCare Cen­ter for Healthcare Value, which ed­u­cates healthcare ex­ec­u­tives on Lean im­ple­men­ta­tion and whose an­nual con­fer­ence in June drew rep­re­sen­ta­tives from more than 300 or­ga­ni­za­tions.


Martin Judd, CEO of Sts. Mary and El­iz­a­beth Med­i­cal Cen­ter, ac­knowl­edges he was skep­ti­cal when he and other Pres­ence lead­ers were asked to par­tic­i­pate in a two-day Lean break­through event last fall. “I drove the team crazy,” he re­calls. “I did not want to be there.”

But af­ter see­ing the out­comes of break­through events at other hos­pi­tals in the Pres­ence sys­tem, he is now an en­thu­si­as­tic sup­porter. “I was floored by what they came up with,” he says. “It re­ally demon­strated to me the power of giv­ing the teams the gift of time to make the work bet­ter.”

Bruce, who steps down as Pres­ence Health’s CEO on Oct. 1, says front­line staffers know how to solve prob­lems, but too of­ten are never asked. “The en­gage­ment level and morale of em­ploy­ees is higher when we bring them into the per­for­mance im­prove­ment work, let them de­scribe the prob­lems, seek out the data and come up with so­lu­tions,” Bruce says.


The Lean method­ol­ogy was de­vel­oped by Toy­ota Mo­tor Corp. as part of the au­tomaker’s vaunted Toy­ota Pro­duc­tion Sys­tem. Like other to­tal qual­ity im­prove­ment method­olo­gies such as Six Sigma, Lean was picked up by U.S. man­u­fac­tur­ers more than three decades ago. Only in the past decade has it found its way into the healthcare sys­tem.

The beauty of Lean is that it en­gages the cre­ativ­ity and skill of the front­line staff do­ing the day-to-day work, says Mark Gra­ban, a Dal­las-based con­sul­tant and au­thor of sev­eral books on Lean. “It’s much more ef­fec­tive than some­one say­ing, ‘I’m go­ing to come fix it for you.’”

Some health sys­tems us­ing Lean hire out­side con­sul­tants. Oth­ers, like Pres­ence Health, have hired their own Lean fa­cil­i­ta­tors. Some are just “dab­bling here and there,” while oth­ers have com­mit­ted to trans­form­ing their or­ga­ni­za­tions through sys­temwide Lean process im­prove­ments, Gra­ban says.

Ap­pli­ca­tion of Lean in healthcare con­tin­ues to evolve. Rather than rou­tinely pulling staff away for week­long rapid im­prove­ment events, Dal­las­based Bay­lor Scott & White Health now lim­its such events to ma­jor ini­tia--



tives. In­stead, ev­ery­one from top lead­ers to clean­ing staff par­tic­i­pates in daily hud­dles to iden­tify and im­ple­ment im­prove­ments. “Ev­ery sin­gle day, ev­ery per­son has the abil­ity to bring for­ward an idea that can close the gap, with­out hav­ing to par­tic­i­pate in a big event,” says Steve Hoeft, Bay­lor Scott & White Health’s se­nior vice pres­i­dent of oper­a­tions ex­cel­lence.

Kath­leen Long, Pres­ence Health’s di­rec­tor of break­through im­prove­ment, says one of the big­gest chal­lenges to over­come in Lean im­ple­men­ta­tion is the com­mit­ment of staff time. “Health sys­tems are so in­cred­i­bly bro­ken, but no­body takes the time to step back and say, ‘Does the way we do this make sense?’ ” she says.

At Pres­ence Health, top ex­ec­u­tives at­tend two­day lead­er­ship events to de­cide which spe­cific op­er­a­tional ar­eas—called “value streams”—such as rev­enue cy­cle, emer­gency depart­ment and sup­ply chain of­fer op­por­tu­ni­ties to boost ef­fi­ciency and save money. The hos­pi­tal lead­ers pin­point spe­cific ar­eas where time or re­sources are be­ing wasted, and plan monthly rapid im­prove­ment events in which front-line staff tackle man­age­able chunks of prob­lems.

At Pres­ence, each event in­volves a nine-step, prob­lem-solv­ing process that in­cludes an­a­lyz­ing the work­flow, craft­ing new goals and pro­cesses, iden­ti­fy­ing gaps that in­hib­ited them from reach­ing the goal, and de­vis­ing ex­per­i­ments to test the changes.

The prob­lem the surgery unit team was asked to ad­dress in Au­gust was the ex­ces­sive time for clean­ing, dis­in­fect­ing and re­stock­ing the ORs af­ter an op­er­a­tion. The slow turnovers de­layed pro­ce­dures, frus­trated pa­tients, physi­cians and staff, and re­duced the vol­ume of pro­ce­dures that could be per­formed, thus cut­ting hos­pi­tal rev­enue. “Free­ing up 6.5 min­utes per case has the po­ten­tial to add $600,000 of added rev­enue over the course of a year,” Long says.

But free­ing up those min­utes is prov­ing to be a tougher task than many on the Lean team an­tic­i­pated.


Af­ter learn­ing about Lean think­ing on Mon­day, on day two the team mem­bers shadow col­leagues do­ing their nor­mal work, iden­tify waste and start brain­storm­ing so­lu­tions. The team hits the surgery depart­ment floor armed with floor maps, stop­watches and notepads. When her­nia, joint re­place­ment and cyst-re­moval oper­a­tions are com­pleted, team mem­bers run to keep up with staffers mov­ing from the OR to sup­ply stor­age clos­ets, to the pa­tient hold­ing area, and to other lo­ca­tions. They time how long it takes.

Some staffers stop to of­fer in­sights. Oth­ers seem irked by the observers. “Holy cow! It was dizzy­ing,” An­drea Ramel ex­claims at the end of the sec­ond day. She is train­ing to be a break­through im­prove­ment co­or­di­na­tor.

Sur­gi­cal tech Vela notes the tremen­dous vari­a­tion in the room-turnover process. Team mem­bers find that com­pleted pa­tients are some­times carted to the re­cov­ery room by a nurse and some­times by a sur­gi­cal as­sis­tant. EHR in­for­ma­tion some­times is charted be­fore pa­tients leave the OR and some­times af­ter. “We need a re­peat­able process,” Vela says.

If the next surgery in­volves a med­i­cal de­vice, the man­u­fac­turer’s rep­re­sen­ta­tive has to be found and brought to the room. But Emily Man­ning, an ad­min­is­tra­tive in­tern who par­tic­i­pates on the Lean team, ob­serves that it’s hard for nurses to co­or­di­nate the ar­rival of the new pa­tient and

si­mul­ta­ne­ously track down the man­u­fac­turer’s rep­re­sen­ta­tive.

There also are prob­lems with stor­age of sur­gi­cal sup­plies, which some­times have to be re­trieved from another floor or are miss­ing en­tirely. Nurse Kostakes says some staffers vol­un­tar­ily come to work an hour early just to pull these sup­plies to­gether ahead of time.

That type of heroic ef­fort, where highly mo­ti­vated staffers de­velop work­arounds in a bro­ken sys­tem, is a clas­sic red flag, says Lean ex­pert Gra­ban.

But the Lean team’s most sur­pris­ing ob­ser­va­tion is that when sur­gi­cal floor staffers are fol­lowed by the team, they con­sis­tently per­form room turnover in 18.4 min­utes, more than five min­utes faster than the tar­get goal of 25 min­utes. The find­ing sug­gests that the turnover time goal could be met if staff mem­bers are sim­ply held ac­count­able.

On the third day, the group is sched­uled to test, ad­just and retest po­ten­tial so­lu­tions to see whether they make an im­pact. Late that Wed­nes­day, the team mem­bers post ideas on how to change the work­flow.

Kostakes says work sched­ules could be changed so that sup­ply stock­ers come in ear­lier to make sup­plies easily ac­ces­si­ble. Iris Me­ne­ses, the house­keep­ing su­per­vi­sor, sug­gests stor­ing sup­plies in a sin­gle place, cut­ting down walk­ing time. Sur­gi­cal as­sis­tant Paresh says the charge nurse should im­me­di­ately tell the room turnover staff when a sur­gi­cal pro­ce­dure is com­plete so they can get started faster.

Then Vela makes her sug­ges­tion that pa­tients be wheeled into the OR by tech­ni­cians. The nurse and sur­gi­cal as­sis­tant push back. As the ten­sion mounts, Barb Cwiak, the surgery man­ager, wan­ders in for a progress up­date.

“We don’t want to of­fer so­lu­tions we know peo­ple won’t do,” Kostakes says with a sigh. The oth­ers nod. “What are the chances they’ll co­op­er­ate?”

Cwiak steps in. “You’re al­ways go­ing to get push­back, no mat­ter what,” she says. “But what­ever this team comes up with, we’ll do.” Ul­ti­mately, the Lean team de­cides to as­sign some of the nurses’ re­spon­si­bil­i­ties, such as look­ing for sup­plies, to sur­gi­cal as­sis­tants and tech­ni­cians to free up the nurses.

The Lean team then pri­or­i­tizes the rec­om­mended changes in terms of dif­fi­culty and level of im­pact. Changes that are too dif­fi­cult or that will have min­i­mal im­pact are re­moved from the ac­tion list. “You try to get im­prove­ments down to man­age­able chunks,” Long says.

Some is­sues end up in the “park­ing lot,” a term for dif­fi­cult is­sues that only hos­pi­tal ad­min­is­tra­tors can ad­dress.


On Thurs­day, the team re­turns to the sur­gi­cal floor to let ev­ery­one know the new way of do­ing the work. They quickly grab staff mem­bers and hand them lam­i­nated sheets de­tail­ing their new as­sign­ments.

A nurse poses so many “but what if” ques­tions that Kostakes spends more than 10 min­utes fir­ing back “then we will” for each sce­nario. “I hope peo­ple fol­low the pro­to­col,” the nurse says be­fore she rushes down the hall to check on a pa­tient.

On Fri­day morn­ing, more than 50 peo­ple, in­clud­ing hos­pi­tal CEO Judd, chief nurse Suzanne Lam­bert and surgery di­rec­tor Kevin Hoak, fill a large con­fer­ence room to hear the team’s fi­nal re­port. Some front-line staffers and lead­ers who par­tic­i­pated in pre­vi­ous Lean events at­tend out of cu­rios­ity.

The Lean team mem­bers con­fi­dently present their pro­posed changes, which in­clude rewrit­ten job de­scrip­tions. They rec­om­mend as­sign­ing Lean team mem­bers to help each shift im­ple­ment the new work pro­cesses. Start­ing Mon­day, there will be a daily hud­dle to dis­cuss cases that do not meet the new 25-minute room turnover stan­dard.

Lean boost­ers say sup­port from top man­age­ment is cru­cial to suc­cess of the pro­gram. Front-line staffers who per­form rapid im­prove­ment ex­per­i­ments “love to have me come in on Fri­days when we have the re­port-outs to hear not only their great work, but to ask for my help in the so­lu­tions,” says Pres­ence Health CEO Bruce.

But the week­long event is only the first step in the process. Data will be col­lected. Re­ports will be is­sued monthly for the next three months. Fur­ther changes will be made. Suc­cess is not guar­an­teed.

Long says pre­vi­ous Lean ef­forts at Pres­ence Health hos­pi­tals have pro­duced last­ing im­prove­ments. Per­haps more sig­nif­i­cantly, they have cre­ated a cul­ture where em­ploy­ees feel em­pow­ered to send is­sues of con­cern up the lad­der to lead­er­ship.

The Lean rapid im­prove­ment process is ex­haust­ing and time-con­sum­ing. But sup­port­ers say it’s one of the best ways to in­crease ef­fi­ciency, re­duce costs, and en­hance pa­tient and staff sat­is­fac­tion. “Show me some­thing else that works, and I’ll try that,” Long tells skep­tics. “We can’t just keep do­ing the same things and hope some­how a mir­a­cle is go­ing to come from the sky.”







Armed with floor maps, stop­watches and notepads, the break­through team at Pres­ence Health fol­lowed col­leagues to see if the changes they sug­gested were hav­ing an im­pact.

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