Lean Healthcare Exchange

As a consultant in lean healthcare, I have the honor of working with individuals and teams who come together to improve their work and the care they provide to patients.  The reason I do this work is the brilliance of the front line staff never fails to amaze me.  I am totally jazzed when I see the light bulbs go on and an idea is transformed into reality that makes a difference.  Recently I observed the evolution of a front line supervisor from skepticism to total engagement as she adopted the principles of lean thinking into her daily work.  With the coaching of a colleague, I was reminded of the change cycle; and the impact on leader’s implementing lean healthcare. 

Uninformed Optimism
Exposed to the possibility of improvement in our everyday work, most of us will be at least a little bit open to change.  Early in a Lean journey, healthcare leaders hear words that philosophically they can embrace; increasing value/decreasing waste, increased satisfaction & quality, decreased cost & time, and increased decision making or empowerment of staff to name a few.  We do not know what will be expected of us, but we know the problems we are dealing with that we would like to go away.  Front line supervisors, generally demonstrate behaviors consistent with such optimism; attending leadership training sessions, volunteering staff to participate in kaizen events,  showing up at stakeholder meetings and asking good questions. 

Informed Pessimism
Following the first request to change our work, informed pessimism frequently takes hold.  Fixing one set of problems will often result in exposing more problems.  Lean healthcare supervisors, who previously made the change decisions, now have first hand exposure to staff making decisions and are confronted with a new reality to support change that was not their personal decision.  Part of supporting that change is holding staff accountable to new standards and coaching staff in solving the newly exposed problems using the scientific method.  It is at this juncture that lean leaders need to reflect on the areas they have control over, instead of looking to blame other departments and the “lean” process.

Informed Adoption
As leaders support the changes made by their staff they adopt valuable skills to promote the lean journey.  Critical to every lean healthcare transformation is leaders moving from asking “who” questions to asking “why” questions. One front line supervisor gave me a terrific example of her own evolution of moving from “who to why”. Following a kaizen event, she learned that clear expectations for what to document and at what time were not in place.  Working with her staff they identified that charting as they went instead of batch charting cut down the time information was available to other disciplines from an average of 32 minutes to 6 minutes.  On further examination, a few of her employees were outliers and appeared to be non-compliant with the new standards. When she went to talk to these employees to find out why, she learned that as night employees utilizing batch charting was difficult due to inadequate lighting on wireless laptops. After implementing new lighting these employees also were able move to one piece flow charting.

 Building Competencies
One lean event or change does not make a lean healthcare organization. Stringing together multiple improvements, such that leaders & staff begin to solve problems using lean principles every day at every level is a sign the organization is on its way. It is in coaching these improvements daily that leaders build their own competency in lean leadership.   Continually reflecting on and building our own competencies is essential to the growth of our organizations. Our organizations can only become lean as fast as we as leaders, including consultants embrace, and change our own behaviors, skills and competency in lean principles. 

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

Often during a Kaizen event, teams discover an area of conflict between individuals, departments, disciplines, or even leadership.  Someone recently asked me if I get tired of dealing with conflict.  The question caused me to reflect on the work done in Lean healthcare organizations and my belief that dealing with conflict effectively is vital to creating an environment where improvement can happen. 

Most of the best Lean Healthcare Kaizen events I have had the privilege to facilitate are made up of cross functional team members.  Each participant brings an expertise that adds value to the patient.  A frequently occurring comment is, “I didn’t know you did that or needed that”.  As changes are discussed, most teams come to a point of having a difficult conversation, otherwise known as conflict.  One reason for the conflict is resistance to change which  is natural and to be expected.  It is often easier to expect others to change before coming to the realization that change is needed in our own work.  I have heard it said, “Change is easy, you go first!”.  It is usually when discussing changes that teams must work their hardest to respect each individual. Conflicts are present even when we do not acknowledge them and only when they are brought to the surface do teams make truly meaningful change.

Lean healthcare organizations grow respect  for people by focusing on the customer/patient, using inquiry to understand each other’s point of view, and exploring options to achieve the best solution & implementation for all involved.  Focusing on the customer/patient is a common goal all team members can get behind and helps to eliminate blame in our conversations.  Teams that inquire to understand a suggested solution, will learn what thinking is behind a solution.  Conversations that uncover each team members thinking  frequently develop solutions that all members can support. 

As  Lean healthcare organizations grow and mature, conflict becomes an expected and productive part of the journey. Leaders and teams know that working through conflict with respect for each other brings increased value for all involved.  Avoiding the conflict will generally lead to countermeasures that are ineffective and an environment that stifles improvement.  Conflict is an opportunity to show respect for the people who make a difference everyday with their expertise, care, and compassion.

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

This week I have had the opportunity to discuss Lean healthcare principles as they relate to our facilities and new facility design. Here are some examples of waste for you to consider:

Defects:  Processes which result in conversations with the patient taking place in a public location, thus violating patient privacy. Furniture for patients which is uncomfortable. Staff interviewing patients & documenting with their backs to the patient.

Overproduction:  Multiple design alternatives created to help elicit decision making from healthcare leadership.

Waiting for healthcare leaders to make decisions.

Not clear/confusion:  Variable interpretations of regulatory standards, particularly around alcoves for storing equipment. Facilities wanting Lean healthcare design without committing to implementation of lean in their processes. Unclear connections between facility design and process improvement.

Transportation:  Last-minute meeting cancellation when others are en route to the meeting.

Inventory:  Storage of supplies behind cabinet doors without standard work for replenishment.

Motion: Excess foot traffic in and out of an operating room that is non-value added,  likely impacting the temperature in the operating room

Excess processing:  Information from front-line staff or stakeholders not provided or obtained early in the process, thus resulting in re-working decisions. 

What struck me as I reflected on these conversations was not just the identification of waste internally within our healthcare facilities, but also how waste in our processes impacts our suppliers. To be effective, our lean healthcare transformations must start internally, and then be shared with our partners and suppliers in order to continually drive increased value to our patients, physicians, staff and community.

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

Over the last decade significant strides have occurred in healthcare to elicit & listen to the expectations of our patient customers. In recent weeks, I had the experience of working with a group of caregivers to design a new process and physical space for pre & post procedure patient care, followed by an experience of staying with a friend before & after a procedure at a major teaching hospital. Interestingly, the second experience validated the design work of the previous week.  

The Lean Healthcare team started the event by attempting to understand the voice of the customer, from patient and family member stories. Several themes emerged from these stories; being informed and known by the caregivers, the need for privacy, space to move around for both the staff and the family, and amenities for family members all rose to the surface. The Director validated the consistency of these stories with the formal & informal feedback received from patients and their families. Lean Healthcare Design solutions centered around having the same staff and physical space for patients and staff, privacy provided by fixed walls instead of curtains or cubicles, flexibility with equipment on wheels and enough space to easily move around the patient.   

In particular the one design concept which stood out for me when I later was sitting with a friend was the need for privacy in pre/post procedure areas. Cubicle curtains were worthless in providing privacy to patients. Curtains by design have a gap to enter into the cubicle and frequently the gap is open at all the wrong times, leaving the patient feeling exposed. Anything being said behind the curtain can generally be heard throughout the unit.  

This simple example reinforces the need to involve our patients and family members as we use Lean Healthcare methodologies to design or improve processes. There are a variety of ways to obtain the voice of the customer when designing new processes, such as patient satisfaction surveys & complaint data, interviews, focus groups and patients as team participants. The key is to invite the customer’s voice into the process, listen to what is being said and respond by building in value as defined by the customer. 

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

As healthcare leaders begin to see with “Lean Eyes” they can quickly become overwhelmed with the amount of waste within their organization. At a recent training session, I was asked the question “Where do we start, there is so much waste?”  My answer tends to vary based on where the organization is in their lean healthcare transformation.  Fundamental to prioritizing areas to work, is looking for the impact that can be made to Quality, Satisfaction, Time and Cost.  No impact, not a good use of your time.

Early on in an organization’s lean healthcare transformation, leadership is focused on how to see waste, understand the tools of Lean, and learn how to support the changes which occur in Kaizen events. At this stage of a transformation, work can be done almost anywhere in the organization to achieve the goals of learning; however, leaders quickly become overwhelmed if Lean work is an add-on to “regular work”. Thus, work must be aligned with the organization’s mission, vision, and operating plan from the very start.  Lean healthcare organizations move on to develop staff in problem solving using the concepts and tools of A3 problem solving. At this phase of the transformation, I look for issues that fit 3 criteria to eliminating the waste:

• Will it matter to the patient (customer)?
• Will staff be less frustrated & thus have more direct time to spend with the patient?
• Is the process within our span of control? 

When first deploying lean problem solving, the key is to start small and build success with the tools. Secondly, whether problem solving is occurring in a Kaizen event or using A3 Problem solving, keep in mind to look for the critical few solutions to achieve the future state.

Mature lean healthcare organizations focus on developing their leaders to coach staff in improving the work on a daily basis. Lean becomes integrated into all aspects of the organization and particularly the tools of Hoshin planning are utilized to focus the strategic & operating plans on the critical few activities to move the organization closer to the stated vision.  

At any stage of a lean healthcare transformation, it is tempting to look for solutions that are outside our span of control. Lean leaders know that change comes best when it comes from within; so don’t wait, just START by eliminating one waste at a time!

This week’s blog was written by Maureen Sullivan, Sr. Associate with Healthcare Performance Partners. Maureen has over 30 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Prior to joining HPP, Maureen served as the director of lean and quality improvement for Exempla Lutheran Medical Center successfully leading the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse with clinical experience in medical surgical nursing, Maureen has held progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen received her associate degree in nursing from Joliet Junior College, followed by a bachelor of science in nursing with an emphasis in healthcare management at Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ).

I frequently have had the privilege of working with some incredibly committed individuals and teams in lean healthcare organizations who share a tendency to being “perfectionists”. A previous mentor often reminded me that the journey is not about being perfect, rather the goal is to constantly pursue perfection to catch excellence. In the pursuit of perfection, lean processes are designed with the goal of being ideal. One aspect of an ideal process is that it is delivered 1 by 1 to meet the customer’s demand. Within most hospitals the concept of 1 by 1 is referred to as “patient flow”, a desired ideal state where patients never wait and there are no bottlenecks in care or treatment. To achieve patient flow, lean healthcare organizations need to eliminate waste and standardize work first in each phase of the value stream and then move on to improving the connections between processes. A recent team, facilitated by my colleague Marshall Leslie, demonstrated the application of these concepts in a group of ED patients who require an assessment and referral prior to admission to the hospital. The team reduced documentation by 50% and sequenced the workflow to minimize interruptions for those conducting assessments. Then they looked at the connections and found solutions to shorten response times from an average of an hour to less than 5 minutes by implementing a 1 call process. So, in your own pursuit of perfection, try looking at the steps before and after the value stream connections for the waste to eliminate then move on to improving the connections.

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen brings over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the Director of Lean and Quality Improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

One of the Lean principles I constantly work on personally and professionally is “building a culture of stopping to fix problems”.  As a staff nurse and later in nursing management positions, I gained expertise in fixing process problems on a one time basis and often using “work- around solutions”.    Why?  The patient had a need and I, like most caregivers, was committed to meeting their need, right now; thus the problem solving had only two steps Problem >Solution.  Unfortunately, the root cause of the problem was not fixed and I and my peers were likely to face the process problem again and again.  Lean healthcare organizations encourage staff at all levels to solve problems with the scientific method.

Clinicians apply the scientific method of problem solving daily when patients present with a problem.  First, an assessment is done to understand the patient’s current state.  Testing is carried out to determine which differential diagnosis is the root cause of the problem.  A treatment plan is developed and implemented and follow up assessments are carried out. 

Lean healthcare practitioners quickly recognize clinical problem solving as A3 Problem Solving, both based on the scientific method.  In A3 problem solving, a problem is identified, which is a deviation from a standard.  The current state is assessed including asking the “5 Whys” to get to root causes of the problem.  A future state is designed and then an implementation plan is carried out.  Measurements are taken to see if the standard is now met, i.e. did we solve the problem.   There is connectivity in the problem solving steps; future state is based on the root causes, measurement is connected to the original problem (standard deviation).

It sounds easy, it makes sense and it takes discipline.  Why don’t we use it? Two reasons, I often hear  and I have personally used, “I don’t have the time, I need to take care of a crisis” and “I am the only one with the problem.”  With the exception of clinical emergencies, there are very few problems within healthcare that do not benefit from stopping to find the root cause.  Even in clinical situations, we have learned to conduct “debriefings or critiques” to identify process  problems and solutions  for future patients. The minimal time spent up front in looking for a root cause pays off in not re-working the solution to the problem time and time again.  The perception of being the only one with the problem is rarely true.  When the problem is brought to the surface, you frequently learn others have the same issue. 

My lean healthcare mentors have trained my brain to intuitively ask these five questions whenever I am with teams trying to solve a problem.  Try it the next time you find yourself discussing a solution, it may help you to “stop and fix the root cause”.
 
1. What is the problem?
2. What is the current process?
3. Why is the problem occurring?
4.  Does the planned solution address the root causes of the problem?
5. How will I know the problem no longer exists?

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

Many caregivers know all too well the frustration of searching for a wheelchair to transport a patient. Wheelchairs are used by multiple clinical departments, outpatients, volunteers, families and even visitors. Often like a grocery cart, wheelchairs are picked up in one location and dropped off somewhere totally different. Until recent increased awareness to prevent the spread of infections, wheelchairs and grocery carts were often not cleaned between uses. 
 
The issue of waste in searching for a clean wheelchair, raised by the front line staff, was the focus of a recent hospital Kaizen event. The facility had already done a great job at 5S and most patient care units had a designated location and par level for wheelchairs. Still only 1% of staff felt wheelchairs were always available when they were needed. Audits found that only 69% of the designated locations had the available par levels of wheelchairs. More importantly to the patient and despite intense emphasis on infection prevention practices, observations of wheelchair use found that only 7% were actually cleaned between use. The event team took cultures from a sample of wheelchairs and found 4 out of 10 positive for bacterial growth. 
 
Lean is about becoming a learning organization through relentless reflection and continuous improvement. Reflection is an attitude and philosophy known as “hansei” in Japan. Reflection is key to moving forward, building on your past rather than starting over with each new improvement.  Lean organizations integrate reflection at an individual level, in day to day problem-solving, and before; during and after kaizen events.
 
In reflecting and building on past work, the wheelchair team modified previous visual markings for wheelchairs by placing pictures at eye level showing staff members cleaning wheelchairs and the number of wheelchairs to be placed in each location. They also ensured cleaning wipes were stocked in each wheelchair location with cards for replenishment. Standard work was implemented for volunteers to round and ensure wheelchairs were up to PAR. 
 
Observation 60 days following the event found cleaning of wheelchairs was carried out 75% of the time.  Time spent by staff searching for wheelchairs was decreased by 50%. The time saved gives back almost two 8 hour shifts per month for staff to spend in value-added direct patient care. Clinical staff at this facility are no longer wishing for a clean wheelchair, they know exactly where to find one and have the supplies immediately available to provide patients with clean and safe transportation. 
 
This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen has over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the director of lean and quality improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. As a registered nurse, Maureen’s clinical experience is in medical surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels. Maureen began her quality management career in 1996, coordinating, facilitating and managing improvement and accreditation programs at a departmental, site and system level within Exempla Healthcare. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.