Lean Healthcare Exchange

Recently it seems that we’re seeing more and more “Rocks” in organizations as we train and guide healthcare organizations through Lean Healthcare Transformations.  I feel this week’s newsletter, which we initially released almost two years ago in Lean Healthcare Exchange, is more relevant than ever and I consider a must read for any organization.  Forward it to the leadership in your organization as well as those within your span of influence. I was in a Wisconsin hospital recently on a gemba walk to review the work of their great staff’s Lean Healthcare journey, and this article was framed and posted on the wall.  They even have “Rocks” identified that they’ve removed, many of which are indeed man made “rocks”! You’ll have to read the article to understand.  If you’ve read “The Rock” before, read it again and ask yourself what you’ve accomplished since last reading it. If the article is new to you, then ask yourself what you’ll be doing to remove “The Rocks” in your organization.  Thanks and enjoy! Charles Hagood

Our team was recently participating in a Kaizen event with a client who was deeply engaged in solving a problem with a very convoluted process.  The team was doing an excellent job and there were several discussions about going to where the work was being done (Gemba), surfacing this problem and getting to a true ‘root cause’ via a “5 Why’s” based approach,  an action rarely taken with past issues.  We were discussing the results of a lean implementation and the fact that by lowering the water level of waste we would uncover a lot of rocks that lay below the surface.  We referred back to a slide in our Lean Leadership presentation and agreed that they had indeed surfaced a rock and were well on their way to breaking it up – hopefully, to never be dealt with again.  The team was doing well…

The Search

Trying to be a good facilitator, I decided that a good visual prop for the team meeting room would be “a rock”. So, I took a walk.  In a grassy median in the parking lot, lay a single perfectly shaped and sized rock for our motivational icon in the training room.  Not only was it the right size and shaped rock – it was a man-made rock of concrete, gravel, and surface pebbles.  Wow – aren’t most of our problems ‘man made’.  This was the ideal visual aid.  I was really proud of myself.

So, I take my ‘perfect’ rock to the training room.  I carefully wrap a piece of tape around the rock to represent the “water level”. And, I write the name of the problem we are solving on the tape.  It does not get any better than this.  I am getting to the point that I may want to take the rock back to Nashville now – just to show it off.  I can’t wait for the next morning.

The Reveal

Bright and early the next morning, in comes the problem solving team. They all see the rock, like the rock, and stand in awe of this great visual aid I had come up with. But strangely, something unusual was happening that caught my attention.  As people began coming into the room, I started hearing: “Hey, I recognize that rock.  I know where that came from”. Of the first six people to come into the room, four had seen the rock and three of them knew exactly where it had come from.  The people at this facility had walked over and around this rock in the parking lot median on their way into the building for several years.  This rock, in reality a chunk of concrete in the middle of a grassy median, had been mowed around, and trimmed around to ensure the area looked neat.

With this, I became very aware that this was no ordinary rock.  This rock was “the poster child” of unsolved problems in our organizations that we walk around and work around, and maybe even make look neat – but it is the problem rock we never get rid of.  It becomes part of ‘the landscape’ – we see it every day.  We know where it is, we know what it is (a problem), and we may even know where it came from. It becomes so familiar to us that we do not even see it as a ‘rock’ anymore – it becomes part of our every day processes and systems.

This rock is the essence of the push for ‘continuous improvement’ and problem solving in a business environment. Lean Healthcare tools teach you to see and observe differently – especially those wastes or problems (rocks) that you see everyday but in fact you no longer see.

Wow!

What a rock.  If it did not weigh 30-40 pounds, I would send you all one. If you want a picture of my rock let me know.

P.S.

The Company liked the symbolism of this ‘rock’ so much they said “it was their rock” and I could not have it.  What a shame – now, if I could just get an inflatable rock to take on trips with me.

By Lean Healthcare Exchange Contributor, Mike Brown, with edits and input from Charles Hagood, Founder and President of HPP. Mike Brown was a Partner in  HPP.  Mike is an experienced Lean trainer and implementer. He holds a BS Degree in Engineering from the US Air Force Academy and an MBA from Troy State University, and was a former F-15 pilot in the USAF prior to his work in industry starting over 20 years ago.

Please take a few minutes to view this Teachable Moment, connecting you directly with the daily work of clinical champions.  Like most of us involved in quality improvement and healthcare reform, you can get immersed in large data sets, randomized trials, flow charts, projections and theories.  Our journalistic sources of information reinforce this.

We are removed from frontline teams making breakthroughs.  As a result, these small discoveries don’t spread and inform others nationally and even globally.

We’ve created a series of Teachable Moments to inspire you with the work of real clinical champions as you pursue your own contributions to health reform.  Hopefully, these new ideas will motivate others to explore the frontiers of discovery.  Just click the link below and spend a moment at the frontline.

Teachable Moment – Reducing Door 2 Balloon Time

Karen Wolk Feinstein, PhD
President and Chief Executive Officer
Pittsburgh Regional Health Initiative(PRHI)

Please take two minutes to view this Teachable Moment, connecting you directly with the daily work of clinical champions.  Like most of us involved in quality improvement and healthcare reform, you can get immersed in large data sets, randomized trials, flow charts, projections and theories.  Our journalistic sources of information reinforce this.

We are removed from frontline teams making breakthroughs.  As a result, these small discoveries don’t spread and inform others nationally and even globally.

We’ve created a series of Teachable Moments to inspire you with the work of real clinical champions as you pursue your own contributions to health reform.  Hopefully, these new ideas will motivate others to explore the frontiers of discovery.  Just click the link below and spend a moment at the frontline.

Teachable Moment – Falls Reduction Program

Karen Wolk Feinstein, PhD
President and Chief Executive Officer of Pittsburgh Regional Health Initiative

If we want to improve a process, we have to be able to measure it. Data collection and measurement are cornerstones of a well-researched, scoped, and defined Lean Healthcare Kaizen event.  Data collection allows us the ability to utilize any number of statistical tools to describe how a given process can be expected to behave.  Standard deviations, regression analysis, trending, and averages all provide useful descriptions of processes.  A measurement system provides us a means to determine if changes have resulting in improvement and if so, the impact on the process.

However, numbers and data can often have a sinister side. How often do we find ourselves immersed in discussions that involve managing data rather than processes? These discussions cleverly hide the waste that comes with them. The discussion might start out by describing that part of the process that is outside of our control. We are being penalized because the numbers reflect things we cannot change nor have influence on. Perhaps we need to develop additional spreadsheets to be able to more thoroughly drill down into the information. We, of course, seemingly always require additional data and information about processes before we can effect a change.  Analysis paralysis sets in and prevents teams from going forward on the things that can be improved.

So why all the fuss about numbers and data? We have to have them right? Of course we do. However, isn’t it ironic that we often immerse ourselves in wastes that are Non Value Added to the Lean Healthcare process we are trying to improve? The focus should be on “moving the ball” in the parts of the process where we can exert significant influence. Honestly, do we really care if the process is measured at 152 or 156 or 145 when we have opportunity to improve the process by 40%. Instead of focusing on the parts within our control where we can make improvement, we spend untold hours changing the way we collect data, massaging the data and discussing why we need better data.  If you think you have at least a 50% chance of success, implement an experiment and measure the results. Teams do not have to be 100% sure that a solution will work before they try it, it can be an iterative process towards the ideal state.

Bottom line, focus on the areas where we expect to have large rapid improvements. I do not believe our patients, employees and other stakeholders care if the number is 56 or 66. They care that we have improved a process by 40% in a way that is sustainable and part of a never-ending process improvement for Lean Healthcare. Improve the process in a way that clearly contributes to patient care, improves the human condition and the rest will follow.

This weeks article was written by Bryan Webb. He is the Director of Facilities Management and the Lean Coordinator at Skyline Medical Center in Nashville TN. He received a BSME from Tennessee Technological University in Cookeville TN. He also has a MBA and Masters of Accountancy from Belmont University in Nashville TN.

This is my opinion column, so I’m going to give you an opinion this week with which many who make a living pillorying the healthcare industry probably won’t agree.

Many of you deserve a round of applause. There, I said it.

After years of paying lip service to improving quality and delivering value for healthcare services and supplies, hospitals are starting to get the message that healthcare providers will no longer be issued free passes for low quality and high costs.

Meanwhile, I can’t really imagine how that message is even making it to hospital leaders, given the fact that our elected representatives can’t seem to agree on much of anything healthcare-related these days.

President Obama still has not appointed a CMS chief, and his healthcare reform effort is going off the rails because of predictable bomb-throwing from the bases of the right and left. One side won’t give up its public health insurance option while the other distorts the truth about current legislation and refuses to make much effort to offer any alternative solutions to the problems of high costs and poor quality. At the same time, we all meekly continue to watch our healthcare benefits erode while our salaries remain static or worse—because healthcare cost increases are eating up any gains.

So back to where progress is really being made, in your hospitals.

Not that you haven’t been prodded to do something about outcomes and skyrocketing costs. From the Institute of Medicine’s 100,000 Lives report to pay for performance from commercial insurers to Medicare’s HCAHPS regulations, you’ve been unloaded on—deservedly—with both barrels in recent years about your inability (as a group) to provide quality outcomes for patients and better value.

I talked to a COO and CFO at two health systems this week. One’s in Texas, and the other is in Wisconsin. They’re both big believers in Lean, a production practice that grew out of the manufacturing industry in which expenditure of resources for any goal other than the creation of value for the end customer is considered wasteful, and a target for elimination. Toyota’s been using it for decades, and indeed, invented it. Other manufacturers adapted Lean to their organizations many years ago, to excellent effect. Now healthcare true believers are doing the same. God knows there’s a lot of low-hanging fruit to be picked from the waste tree in healthcare. I’ll tell you about some of them in next week’s column.

Why are they doing it now? Well regardless of what happens with healthcare reform—and it looks like “nothing” is at least an even bet right now—hospital leaders know their long-term future is tied to efficiency and cost control.

So go ahead, give yourself a pat on the back.

Now, get back to work.

The article was written by Philip Betbeze for HealthLeaders Media.

“Accountable Care Organizations” (or ACOs – also referred to as “accountable care systems” and “accountable care entities”) are posited as new structures through which groups of providers can integrate patient care, with shared financial incentives for quality and patient outcomes.

Large, multi-disciplinary health systems are well-positioned for the ACO model. Such systems, however, comprise a small fraction of the entire healthcare system. Small practices and community hospitals, which are the backbone of health care in most areas, typically lack resources and expertise required to coordinate care across settings for patients with complex, chronic conditions. Rather than developing directly into ACOs, smaller, independent hospitals and practices may need outside assistance and time to work through a transition phase – as accountable care networks. The nature of these transitions, related new initiatives by the Pittsburgh Regional Health Initiative and implications for health reform are described at: “Accountable Care Networks: Transitions for Small Practices and Community Hospitals.”

We welcome your comments, questions and ideas.

This article was written by Karen Wolk Feinstein, President and Chief Executive Officer of the Jewish Healthcare Foundation, Pittsburgh Regional Health Initiative.

This post is from my friend Dr. Karen Feinstein and our partners at PRHI.  Please read the story below.  It should make the case for Lean in Healthcare if nothing else does. Thanks, Charles Hagood.

Over this past weekend, a dozen major newspapers from across the country featured a disturbing new report (“Dead By Mistake”) about the national failure to reduce medical errors http://www.chron.com/disp/story.mpl/deadbymistake/6555095.html).
 
More than a decade after the Institute of Medicine estimated up to 98,000 patient deaths annually as a result of preventable medical errors, there has been no measurable improvement in patient safety (according to the 2008 National Healthcare Quality Report from the Agency on Healthcare Research and Quality, complied annually by the Agency for Healthcare Research and Quality).  As a result: 

• Estimated preventable patient deaths still equate with a daily, 100%-fatal jumbo jet crash.
• Wrong-site surgeries in Pennsylvania alone exceed annual U.S. coal mining deaths.
• More die each month of preventable medical errors than died in the September 11th attacks.

Waiting another ten years for improvement in patient safety is simply unacceptable.  Particularly frustrating are thousands of patient deaths that result from frequently recurring medical errors for which proven preventions are already known.  The Pittsburgh Regional Health Initiative (PRHI), which has been for a dozen years a state and national leader in patient safety, recommends  that Congress create a national patient safety agency — to focus on recurring errors.  Detailed PRHI recommendations are at:  http://www.prhi.org/docs/The%20Need%20for%20a%20Federal%20Patient%20Safety%20Agency.pdf
 
Under the PRHI proposal, no federally mandated reporting would be required; no new federal research would be needed to address scores of recurring errors that cause thousands of deaths and cost hundreds of millions of dollars.  For example:

• Hundreds of wrong-site surgeries annually due to lapses in established pre-surgery protocols.
• Hundreds of deaths and thousands of injuries due to look-alike and sound-alike medications.
• Thousands of errors daily due to non-standardized color-coding of patient wristband IDs.

PRHI has for more than a decade underwritten clinical projects that have proven hospital-acquired infections, medication errors and other safety lapses to be preventable — e.g., 68% reduction in central line-associated bloodstream infections among more than 30 Pittsburgh area hospitals; virtual elimination of antibiotic-resistant staph infections at the Pittsburgh-VA (now national VA policy).

We welcome your questions and comments – and, if you agree with us, your help in pushing for long overdue action on patient safety.

Below is a great article, written by Paul O’Neill, published yesterday in the New York Times, Titled “Health Care’s Infectious Losses”.  I’m not one that desires to engage in political debate, although I do want to promote the debate in how to best remove waste from health care, in all shapes and sizes.  All of these goals are achieved utilizing Lean Healthcare Principles, as difficult as it may be to change our healthcare system’s way of thinking. Recently I was discussing the same question presented below with a group of hospital executives regarding the healthcare debate in Washington, “Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste”.” Although I’m a fan of technology when used in a Lean fashion, EMR/EHR alone will not remove the waste.  It is likely when not planned carefully to expedite the speed at which we can make errors and create additional waste if not removed from the process beforehand.  I do believe that such questions below must be asked and acknowledged by all in order to make our system the best it can possibly be. Regardless of how the system may look in the future or which side of the aisle you’re on, such debate is not only healthy but essential.

In conjunction with Karen Feinstein, PhD, Paul O’Neill was a co-founder of the Pittsburgh Regional Health Initiative (A Partnering Firm With HPP), which was a pioneer in the application of Lean Principles into the healthcare industry to promote efficient, safe, and reliable care. Let’s join together in asking these questions of each other.  Enjoy the article! Charles Hagood
 
New York Times
July 6, 2009
Op-Ed Contributor

Health Care’s Infectious Losses
By PAUL O’NEILL
Pittsburgh
 

HEALTH care reform seems to be on the way, whether we want it or not.

So I have been asking questions about the various proposals. Here is a sampling.

• Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?
• Which of the proposals will eliminate the annual toll of 300 million medication errors?
• Which of the proposals will eliminate pneumonia caused by ventilators?
• Which of the proposals will eliminate falls that injure hospital patients?
• Which of the proposals will capture even a fraction of the roughly

$1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?

So far, the answer to each question is “none.”

Let’s consider that $1 trillion of waste. If we could capture all of it, the savings over 10 years would be five times what President Obama has said he will extract from insurance companies over the same period. The president’s vision of bringing down health care inflation by 1.5 percent a year over the next decade would not be a victory, but a capitulation to the enormous waste in the delivery of medical care.

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. But excellence is possible, and it has been demonstrated.

Where it works, the common denominators are strong leadership and a committed work force. Among those doctors showing the way are Brent James at Intermountain Health in Utah, Gary Kaplan at Virginia Mason Clinic in Seattle and Richard Shannon at the University of Pennsylvania, who have helped bring infection rates down drastically at their own hospitals and at others.

Hospitals and medical schools have great impetus to increase the ranks of such doctors: these improvements in patient care don’t cost money, they save money. And they represent only the tip of the iceberg in opportunities for improving outcomes and reducing costs at the same time.

A next step would be for the government to finance a prompt, detailed and hard-headed study of every example of error, infection and other waste in five major medical centers. Such data would give policymakers and caregivers a clearer picture of the possibilities for cost-saving improvements.

It would also help if reporters and pundits became more informed about the opportunities for improvement, so they could help educate the public and improve the level of the reform debates. As for members of Congress, perhaps it would help them to understand the problem if we assembled the data, by House district, on hospital-acquired infections, medication errors and other waste indicators. They are more likely to push for the right sort of change when they realize that people they know and represent are being hurt or killed by practices we know how to stop.

In the end, any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.

Paul O’Neill was the secretary of the Treasury from 2001 to 2002.

Below is a commentary that speaks to the power of Lean Healthcare, Kaizen, and having a strong facilitator to drive rapid process improvement and deliver results. I hope it resonates with you.

Hi Dwayne,

While the week is still “fresh” in my mind I thought I’d write you a note, including some of my perceptions after the Kaizen event week.  As you may or may not know, I took the position of Chief Operating Officer of our Behavioral Health Campus in February, 2007, so have been here 15 mos.  The campus continues to be in transition from the acquisition by a proprietary healthcare company of a faith-based, non-profit hospital.  This explains some of the resistance to progress over the last three years.  Many of our long-term staff continue to grieve what was, even in the face of much needed change.

The Options Dept. is the Department most likely to contribute to either the success or failure of this organization going forward.  It is ripe for change and its new manager needs support as she executes the necessary changes.  This Lean Healthcare event lent great support to her.  The Options staff selected to participate are staff with significant personal power in the department so the selection was strategic.

I was initially cautious about enthusiastically embracing this event, for fear it would be a “flash in the pan” of yet another aborted start of something good, or fail to follow-through with the work necessary to assure its success.

What I found the first day was a facilitator highly skilled in leading groups, operationally knowledgeable about the “mechanics” of the process, an excellent listener, and an empowering leader with a sense of humor, timing, focus and a drive toward time management and outcome.  He was direct in his feedback, honest in his criticism  (which was always constructive), and unafraid to call us on a less than helpful dynamic.

As the administrator of newly acquired hospital, I feared the cost/benefit ratio might prove to be less than I hoped for.  I was delighted and surprised!  Not only was our department united, but the relationship-building with the emergency department was well on its way to healing by the end of the week.  The “hands-on” approach to quickly trying a new idea, rather than creating a week of theoretical, but untested constructs, made a believer out of me! 

I came to the hospital this weekend and was anxious to see if the new board in Options was being used consistently and if there was “ownership” by the Options staff in the new process.  I received a thank-you note from one of the participants who was also working this weekend.  In his email, he thanked me for allowing him to participate in the process.  I can’t wait for the 30-day return to evaluate progress made and  explore additional opportunities to improve the department.  I believe that the Kaizen event has allowed this department to  become “unstuck”, physicians to become engaged in the admissions process, and that the outcomes will have measurable volume and revenue gains.

Thank you for providing this exceptional experience.

This commentary was written by Kay Delage, Chief Operating Officer at Skyline Medical Center located in Madison, Tennessee. Skyline is a part of the TriStar Division of Hospital Corporation of America. Kay holds both Bachelor’s and Master’s degrees in Nursing and has 27 years of behavioral health experience as a nurse, Director of Nursing, Chief Executive Officer and Chief Operating Officer.

This week’s newsletter comes from my good friend Leslie Wright of the NHS system in the United Kingdom.  Leslie and her colleagues in the UK are working hard to take Lean Healthcare throughout the system.  The article below highlights the universal need in Healthcare for not only 5S as a basic principle of Lean, but in the constant need for highlighting the waste of  “excess inventory” in healthcare settings.  Whether it is a US for profit hospital, or a national health system in Europe, the waste is similar.  Hope you enjoy and learn something from this basic lean healthcare principle that we can all learn from.  Charles Hagood

No body could have escaped the intense publicity surrounding the global credit crunch and the difficult financial situation many are facing.

One of the most common tools used in Lean methodology is 5S, and is the foundation for standard work.  5S enables teams to focus on the root cause of waste, establishes standards for basic organization and orderliness that improves work flow.

The 5S’s refer to Sort, Straighten (or Set), Shine, Standardize and Sustain.

Sort – the work area is cleared of all items that are not required to undertake the specific duties of the designated process.

Straighten (or Set) – makes sure that all items required to perform the task are set in the correct place ‘a place for everything and everything in its place”. Critical items for the process are marked with a foot print or shadow board, when something is missing it provides a visual signal, and can often signal ‘danger’.

Shine – once the area is cleared of all extraneous material the area can be cleaned

Standardize – the opportunity to set in place standards for operating

Sustain – the 5S process is audited and monitored on a daily or weekly basis.

Frequently during this 5S process we have come across some significant volumes of inventory and some surprising and unusual finds including:

• 500,000 sheets of paper – 4 years supply
• 3 years supply of envelopes
• 9 years supply of diagnostics testing medium
• 9 years supply of bleach
• 14 months supply of ink cartridges
• Out of date scalpel blades and reagent
• 990 tea spoons in a pathology basement!

This is what many refer to as stock; Lean calls this Inventory, where excess and out of date supplies are stored in the workplace. All inventory takes up space, although a frequent complaint from many staff is the lack of space, and of course space costs money too. More importantly, is the amount of money invested in this “stock”, some of which could be out of date before it even used.

Take for example paper for printing reports, which are pre printed with the hospital name and logo, designed for a specific type of matrix printer. When 6 years supply of paper is purchased and a generous discount is given for bulk purchase -  it seems like a good deal. When an opportunity arises to replace the old troublesome printer, with a faster more efficient and reliable printer, a four year supply of useless paper is the result. The storage space required takes up a whole storeroom for this one item, time required to disposition its status and so on. What seemed like a good opportunity has now become a burden and the waste of “excess inventory” and a financial cost pressure.   Frequently systems have been set up because of a single previous failure in the supply chain turning everyone into squirrels and the hording of inventory, which is further compounded by the lack of visual management of the inventory.

Would we apply this process to our own weekly domestic purchases to save a few dollars in the short term?  The next time you go to your local supermarket would your shopping list be:

• 9 years supply of cornflakes
• 3 years supply of baked beans
• 500,000 toilet paper rolls
• 14 months supply of bread
• 6 months supply of apples

Can you afford to do this? , Do you have the space to store this amount of inventory or the capital to build more storage space? How many of the items will be out of date before you can use it?

Whilst the NHS is prepared to order and store goods in these quantities, suppliers have no need to invest in warehousing facilities given the NHS has become the free warehouse.

This article was written by Lesley Wright, the Director of Diagnostics for NHS Improvement in the UK, and is a colleague of HPP in her Lean work in the NHS system.