Lean Healthcare Exchange

I admit it! I am in love with my iPhone. It is my single most important travel accessory—no—life accessory I possess. I have not always been so passionate about a cellular device. I have been an extreme business traveler for over 10 years. Yes, there have been others that have brought me momentary pleasure; that excitement that only comes from being among the first to get the latest smart gadget or palm perfect tool.  None have sustained my desire like the iPhone.

My adoration recently went much deeper than the iPhone’s simple intuitive function or the endless assortment of apps to solve any problem that exists. It is now a loyalty that transcends the hardware. I knew it was true love the day I had to take my beloved in for service at the Apple Store’s Genius Bar.

Previous wireless providers had left me severely scarred by the painful memories of crowded stores, long lines and unending frustration. Seriously, at what point does waiting for the root canal become more painful than the root canal itself? After some reassurance from my 23-year-old daughter, I made an online appointment with the Genius Bar at the Apple Store. From that moment, as they say in the iPhone ads, ‘This changes everything.’ I became a diehard Apple loving convert.

As I entered the Apple Store at 4:35pm, I immediately noticed the large number of customers in the store. There was no greeter – no information desk or sign-in kiosk, no lines and yet the many customers inside were moving about, stopping to interact with the various Mac products on display. There was no overhead paging. There was no waiting room with a TV or prominent service counter lined with computer monitors for these “Geniuses” I was to meet. Instead, there were two large wall-mounted monitors that displayed the first name, and last initial for the appointments in queue. My appointment was scheduled for 4:45pm. There were five people in front of me. My instincts told me, ‘This is going to be like a trip to the DMV,’ but, fascinated by the customer flow before me, I moved to a neutral corner and just observed the action.

The large monitors rotated through valuable quick tips for improving the use of various Mac devices while returning to the appointment queue about every 30 seconds. There were well behaved children playing computer games at a kid-sized work table. Others walked in with their Mac Books and made their way to their scheduled education sessions at the Training Bar. Accessories lined the walls; a myriad of gadgets and gizmos for every iPhone and iPad need. At precisely 4:45pm, a young “Genius” named April emerged from a small group in the center of the store and called my name. “Teresa”? I walked closer to her as she introduced herself and shook my hand. April listened to my iPhone issue as I explained the symptoms. As she examined the “patient,” she pulled what looked like an otoscope from the tool pouch attached to her belt. Obviously very knowledgeable, April explained each step she was taking to determine the cause of the problem. April used her personal iPhone to look up my account and warranty information. Empowered to make decisions, she explained the steps she would take to resolve the issue and even printed a copy of the work order for my employer without ever stepping away from me. At 4:51pm my issue was resolved and I was on my way.

Now, as with any process, it was not entirely without waste; I left the Apple Store just in time to get stuck in Nashville’s rush hour traffic. The bumper-to-bumper drive home did give me time to ponder the same questions I now pose to you:

• Can this kind of experience be consistently achieved through Lean Healthcare initiatives?
• Are we promoting customer service or enabling inefficient processes by designing large waiting rooms with comfortable amenities?
• Have we really challenged ourselves to simplify access to the healthcare services we provide?
• What does the healthcare customer of tomorrow really want and how can we leverage Lean Healthcare thinking to provide it?

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

As a nurse with many years “in-the-trenches”, one of the most frustrating realities in the hospital is the inconsistencies associated with relatively standard spaces and work tasks. Two identically functioning rooms on the same floor such as a medication room can have unique features and inventory that force wasted motion and effort in order to complete the routine task of medication delivery.

Why can’t highly repetitive spaces such as a medication room, nourishment room or even a med-surg patient room be truly standardized so that no matter where you are deployed to work, you are instantly familiar with the environment and standard work is accomplished without the waste of searching for supplies and equipment?

There are many challenges associated with not only creating facility-wide standard work but more importantly sustaining it. Unless a facility was designed using Lean Design principles such as standardization, room sizes and shapes are rarely identical, forcing differences in work flow, cabinetry configuration, and ultimately storage capacity. Without established standards and a strategy to maintain them, rooms with the same purpose have general similarities but lack the structure necessary to sustain standard work conditions within a Lean Healthcare facility. Many times each day a single trip to a medication room turns into much more than the clinician bargained for – after rummaging through every cabinet and drawer for a syringe that was supposed to be routinely stocked in the room, the nurse finally gives up and walks to another medication room or the clean supply room to complete what should be a simple medication administration task.

Without a doubt, designing new construction using Lean Design principles is ideal. However, Workplace Organization can help mitigate the lack of physical standardization plaguing the healthcare environment. HPP recently got the opportunity to tackle both standardization and sustainment on a large scale by using Systematic Workplace Organization strategies in a new 125-bed community hospital. With military style planning, 40+ highly repetitive prototype rooms were identified and developed with the input of bedside caregivers.  The prototypes were then mass produced through a cloning process that spread workplace standardization over the entire facility using 5S and Visual Management principles.

As the hospital prepares for its ribbon cutting next month, the benefits and cost savings are becoming immediately apparent. Staff orientation to the new Lean environment is easier. There are fewer supplies in inventory than a facility of similar size and staff feedback regarding their satisfaction with their work environment is extremely positive. Most importantly, the hospital’s Lean Journey will continue forward on a foundation of widespread workplace organization.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

Our beloved principle of “standardization” is frequently put to the test in the Lean Healthcare Design realm when outfitting a large number of repetitive rooms. Even creating a standard which includes placing a low cost item such as a suction regulator in each med surg room can add up quickly.

Creating an ideal state most often includes the development of a standard. Sometimes the trade-off for standardization is lower utilization. Let’s use the case of the suction regulator to illustrate:

1. Safety – Immediate availability of suction is one of those clinical interventions that can be a critical and unexpected need. It definitely meets the safety criteria.
2. Convenience – In many hospitals, regulators remain in the “last-used room” location. The nursing staff launches a scavenger hunt when a regulator is required in another room without one in place. It is certainly inconvenient and frustrating when trying to set up for a new admission or change inpatient condition. Numerous travel steps can be avoided by applying one of several lean tools.
3. Patient type – One of our community hospital clients recently estimated that only 10% of their med surg patients required suction. This hardly justifies the case for a suction regulator in every room. In med-surg, certain types of patients will require suction more often. Depending on how much you are able to cluster these patients, utilization may be higher – making 100% standardization more appealing for a smaller area.
4. Cost – Initial cost is probably more than you want to spend, but it is non-recurring. With the proper lean tools in place, you can be sure that replacement cost will be minimal.
5. Attrition – Without lean controls, small devices such as regulators have a tendency to disappear over time. They are like socks that go into the dryer. Where they go is anyone’s guess!

What if there is no money in the budget to have a suction regulator in every room? In this case it becomes even more critical to have a Lean system in place. Below are just a few ways to apply Lean Healthcare Principles to the suction regulator dilemma.

• Create a dedicated location for a suction regulator(s) on each hallway with a kanban system for replenishment when the item is put into use.
• Use visual management principles to create staff awareness when the item is missing and requires action for immediate replacement.
• Establish a process to remove suction regulators from rooms at the time of terminal cleaning to return them to the inventory cue. This could even be built into a check list used by Environmental Services.
• To manage the “critical need” issue, place a regulator on the crash cart as part of the basic inventory to ensure that no one is ever caught without a regulator in a time of crisis.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

As hospitals and healthcare systems struggle to balance rising cost with reimbursement, capital investments such as building renovation and expansion must bring tangible savings through enhanced environmental and operational efficiency. Requests for expertise in Lean Design Services in architectural proposals or RFP’s are becoming very common.

It is true that new construction offers a unique opportunity to correct years of process workarounds and suboptimal space utilization.  Lean healthcare principles can be used effectively to guide the development of optimal future-state processes which can then be applied to create a supportive architectural design.  The opportunity for improved patient outcomes while reducing or eliminating waste can be unprecedented. Unfortunately, the benefits of Lean cannot be realized through Lean healthcare design alone.

Important considerations before employing Lean Healthcare Design:

• New facility design can support Lean processes, but it is essential that the organization’s leadership team be enthusiastically committed to beginning or continuing its lean journey toward waste-free work.
• Lean does not end with building completion. Lean healthcare processes must continually evolve after building occupancy and the design response must offer the flexibility necessary to accommodate change over time.
• The concept of “standard work” must be embraced throughout the organization at every level as part of its culture in order to achieve the full benefit of the Lean Design. This can be more difficult than it sounds. Department managers must agree to standardize work processes across departments. For example, unit secretary workstations and work processes are identical regardless of location within a facility.
• The comprehensive use of visual management tools and standard placement of supplies and equipment are necessary to promote and sustain Lean processes. Communication boards, visual kanbans, and designated parking spaces for mobile medical equipment promote seamless transitions between caregivers prevent staff from searching for needed items.
• Adequate staff preparation and Lean training is vital to patient and staff satisfaction as well as waste reduction. The staff must embrace the Lean processes that actually drove the building design. This cost is often underestimated.

If “going Lean” were easy, hospitals would no longer need waiting rooms. Nurses would not hoard supplies in the pockets of their uniforms and patients would never get hospital acquired infections. When a Lean healthcare organization can deliver healthcare in a supportive Lean environment, the successes achieved in the manufacturing world to eliminate waste and defects may actually be possible.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

Imagine for a moment that you have never flown in an airplane. Today, you will be taking your first flight and confess to being a little nervous and unsure of what to expect.

Approaching the ticket counter, you notice several partially destroyed pieces of luggage stacked among the mountain of paper files along the wall. The ticket agent, appearing frustrated, mumbles “where are the luggage labels? I hate working here”. The agent looks up and blurts out “Destination?”  You begin to explain that you bought your ticket on Expedia and more than one airline is involved. You are quickly interrupted with the next verbal command, “Name”? After several minutes, the flight information is located and the boarding pass is issued. You are told that there are no luggage labels and you must take your luggage to another ticket counter to get it checked. Worried that you will never see your luggage again, you follow the instructions and hope for the best.

Feeling quite proud of yourself, you survived the gauntlet of security screeners and make your way to the gate. Following a 2-hour delay in departure due to mechanical problems, you are about to board the plane. As you make your way down the jet-way, you notice numerous brief cases, bags and boxes. Seeing no explanation for this, you keep moving with your personal belongings on to the plane. No one greets you as you enter. Walking down the aisle, you pass two seats with crime scene tape and a “Broken” sign across them. You quickly begin to realize why the bags were on the jet-way – the overhead compartments are overflowing. You locate your assigned seat, only to find another passenger claims to have the identical seat assignment. Ringing the flight attendant call bell, you contemplate whether you should attempt to just get off of the plane or keep fighting for the basic services for which you paid.

Would you want to fly this airline? Would you feel confident that the flight would make it safely to its destination after so many problems?

Consistent application of lean principles could drastically improve this first time flyer’s experience.
• 5S Points of Public Reception
• Consistent Staff Training
• Squeeze the Waste out of Front End Value Streams
• Institute Proactive Preventive Maintenance
• Clear Visual Management for Customers and Staff

A hospital admission or outpatient procedure can be as intimidating as a first time flying experience.  Customer perceptions, both positive and negative are shaped by the queues along the value stream to obtaining that product or service.  As busy healthcare providers, we often become numb to essentially identical frustrations to those described in the airline scenario. It is important to step into the gemba, look at the patient experience with fresh lean eyes and ask the question, “Are we promoting a positive first impression? Would our patient intake process frustrate or satisfy me if I were the customer?”

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

As a Lean Clinical Design Consultant with 10 years experience working along side well meaning hospital employees in the planning and design of numerous building projects, I have come to recognize the signs and symptoms of a very insidious infirmity. I have termed it Post Traumatic Space Deprivation Disorder or PTSD(D). It can dramatically distort reality, lead to improper allocation of square footage and interfere with project goals such as improving the quality of care and operational efficiency.

Just as is the case of the mainstream mental health affliction, post traumatic stress disorder, hospital caregivers have endured great difficulty, frustration, and even helplessness in performing their daily responsibilities. They have battled the inefficiencies of aging, antiquated environments with semi-private patient rooms, cluttered workspaces, and distant, small supply closets. When called upon to participate in the design of a new work environment, excitement can quickly turn into anxiety. Making decisions about process and space can be overwhelming even for lean thinkers.

Even under the most ideal circumstance, as when an organization is one to two years into their lean transformation, the typical design process focuses on floor plan development by individual departments which can create work process barriers for today’s extremely multidisciplinary treatment model. Left unchecked, PTSD can negatively influence attempts to reduce waste in the new environment and even contribute to the most dastardly budget buster; scope creep.
The symptoms associated with PTSD are remarkably similar to those of its medical counterpart. Early recognition and aggressive treatment is essential in overcoming the negative effects of PTSD.

Symptoms of Post Traumatic Space Deprivation:

• Flashbacks – Valiant attempts to recreate a perceived happier time in the past (like medical school or a previous work situation)
• Bad Dreams – Exaggerated memories of the rare or occasional occurrences when limited space or capacity caused delays in patient care delivery. (”Feeling like you must build the church to accommodate the crowd on Easter Sunday”)
• Frightening Thoughts – An uncontrollable fear of not having enough storage space, windows and bathrooms.
• Rationalizing – Creating endless logical reasons for maintaining sub-optimal or dysfunctional current state processes. (Holding on to “the way we do it now”)

Steps to Overcoming Post Traumatic Space Deprivation:

1. Get on the Lean Path and Stick to it! – It is never too late to begin transforming culture and process using lean thinking. One word of caution – Lean design is a little like purchasing a size 6 wedding gown on clearance in January and vowing to lose 50 pounds before your June wedding. There are no refunds on new construction if you have “fallen off the lean wagon”!
2. Value Stream Map Current State Processes – Value stream map current state processes and pay special attention to understanding how the environment may have shaped process. Identifying existing building barriers will prevent them from being transferred in the new environment.
3. Perform Direct Observations – There is no substitute for going to the Gemba or where the work is done. It is rare that the reality of direct observation matches how the process is perceived to be working.
4. Utilize 3P (Production Preparation Process) – Develop ideal future state processes by focusing on waste elimination in process design. Lean processes can then accurately inform the architectural design.
5. 5S the Current State Environment – The exercise will not only give design participants a more accurate picture of how much space is really necessary to accommodate supplies and equipment in the future state, it will improve efficiency and staff satisfaction with the existing work environment.

PTSD can be overcome through diligent application of basic lean principles. Design team participants can redirect their natural human tendencies toward more value added design solutions that focus on healthcare’s most important customer – the patient.

This week’s blog was written by Teresa Carpenter, the Director of Lean Clinical & Facilities Design at HPP. Teresa brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in the acute care environment, Teresa moved to our Nashville area where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Among these projects, she was the lead planner on the nationally recognized St. Joseph’s Hospital in West Bend, Wisconsin, the world’s first hospital designed to reduce medical error. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.