First 90 Days as Hospital Lean Director – What To Do?

Lean Leap to Health Care #9 (Click for Part #8) by Scott McDuffee

“I'm not sure if I have ever learned anything with my mouth open. But, I know I learn a lot with my eyes, ears, and mind open.” Sitting in front of Buffalo wings at my second office with my co-conspirator and accountability partner Steve, we skipped our normal job search strategy session in lieu of a first 90 days plan for the job he landed.

His request got me thinking: how would I structure my first 90 days as a lean champion in Health Care? First, it would be valuable to reflect on the journey in manufacturing then look to books like Lean Hospitals and Going Lean: Busting Barriers to Patient Flow.

There was a whole punch list of topics we engaged along the journey which could be useful for my first 90 days in Health Care. I would want to know more about the financials, measures, accountability, org structure, culture, patient /physician/staff survey trends, information systems, media perceptions, and competitors/benchmarking. I could easily focus on 5S, spaghetti diagrams, materials replenishment, quick change-over, first-pass-yield, scheduling, and many other tools.

“Dig where the gold is…unless you just need some exercise.”
– John M. Capozzi

Along our manufacturing lean journey, this quote often helped funnel our approach toward the concepts of Rother and Shook's Learning to See. The answer to our “Where do we start?” question echoing sage advice about Value Stream Mapping from one of my early and long term mentors mentioned previously, David Mann.

David emphasized starting closest to the customer, understanding value and pace of demand. Then, working upstream always keeping the customer in mind. Flow where-ever you can, pull when you can't, never push.

David also reminded us to use a pencil and “go see”. We often referred to this as “putting the cook in the kitchen”. Don't sit in a conference room. Instead, go observe the actual versus someone “intellectualizing” about the work or remembering how much wait time / inventory is between operations. Go get a snap shot of the current state. Go measure. Go count. Observe at Gemba.

Although this process led us to successful initial focus on relatively repeatable processes with a probability for success, then working from final assembly all the way back upstream through the supply chain. This may or may not be the right 90 day focus for a hospital.

So, I looked to Lean Hospitals by Mark Graban for advice. Chapter 11 is called “Getting Started with Lean,” which seemed like a good place to pull some notes of concepts that resonated with me from a 90 day plan standpoint.

It makes sense to focus on one value stream or area instead of spreading resources and focus too thin. Also, Mark advises against approaching lean with a focus on a certain tool, instead focus on important problems determined by asking the questions:

• What is a patient safety problem or risk to solve?
• What are the most pressing complaints from patients?
• What major issues do physicians or other employees bring to your attention?
• What departments have been struggling with employee shortages?
• Who is proposing an expansion or renovation of their space?

Also insightful for my 90 day planning, according to Mark Graban's survey of 50 hospitals, lean initiatives were started with the following motivations (allowing for multiple responses). David Letterman-esque, The Top Ten Reasons for Lean Hospital Initiatives Are…

20% Emergency Department Waiting Time
30% Need for Growth
34% Patient Safety (proactive)
38% Labor Costs
38% Employee Satisfaction
42% Overall Cost Pressures
44% Culture Change
50% Labor Shortages
50% Patient Satisfaction, and the number one motivation for hospital lean initiatives,
56% Quality and Rework

Yet another alternative from Lean Hospitals to determine where to start is sharing a lean overview with the staff then base your decision on someone who volunteers or really wants to engage lean principles in their area. Essentially, look for the “pull signal”. It is wise to build on strategic successes. It is un-wise to train en masse and expect results to just happen.

Yet a third way to determine where to start, according Mark, is to perform assessments. Common tools include Value Stream Mapping as well as observations and employee insights. Many hospitals start in areas which are more “production like” such as laboratories and pharmacies. Ultimately, where to start is a situational “It Depends”. Culture should be taken into account – specifically the appetite for change.

Mark emphasized one should never implement change without a plan to sustain. Leader Standard Work and 30, 60, 90 day metrics {Plan, Do, CHECK, Act (or Adjust)} should accompany the many forms of kaizen (good change). The importance of change management cannot be over emphasized. As much as 90% of the challenge of lean implementation is related to people and their acceptance of change.

My 90 day plan is coming together. “It Depends” and “It Depends on People” aggregates a lot of wisdom with the principles shared in Lean Hospitals to pave the way.

“Going Lean: Busting Barriers to Patient Flow” from the American College of Healthcare Executives (ACHE Management Series) was another reference. Although the title says “Lean,” much of the text seems to be Theory of Constraints methodology. There are some great points to help guide my first 90 days here as well. I scribbled down more notes from the text as reference for my 90 day plan.

We need to understand how efficiency at a point (batching / point velocity) must be overcome to maximize patient flow (minimize patient time through the system). In “Going Lean,” Smith, Barry, and Brubaker, use the example of one large elevator in comparison to an escalator to drive their points home with something to which most can relate.

Echoing this message, “The Lean Management Method moves healthcare from its traditional task orientation to provide better patient service, better patient care, and better utilization of assets.”

If patients, payers, and providers are in favor of moving the patient more briskly and smoothly through the system, why isn't it happening already? The key can be cooperation with physicians and with administrators.

According to Nobel Laureate Herbert Snow, three determinants are necessary to drive changes to culture and behaviors. For strong change management processes, determine:

“1) how to get the important problems to the top of the management agenda, 2) how to represent the issues in a way that others can understand them, and 3) how to represent the issues in a way that facilitates solutions.”

When I read this, value stream mapping again came to mind as well as the practical language emphasis received from insights from the comments on this blog – speak in the tongue of the natives. Good affirmations but what is the real “take away” for me for my 90 day plan?

Here is something. Hospitals today often do well at optimizing a department or a stand-alone process but they need to become strong at optimizing the whole from the patient perspective. This does not mean to just “work harder”. Instead, it means measuring success differently – and thinking differently. Okay, I get this. Makes sense.

Then, I had an Aha! Moment while reading a Going Lean segment called, “That's the Governor on the Stretcher.” I hadn't connected the dots before now but I had a similar epiphany on my first kaikaku of the conference chair line in manufacturing.

After trying (and failing) to implement lean by sharing the vision and the principles in a professorial style, I walked out on the floor in the fall of 2000 to ask the working leader Chris, “Assuming a national sports team wanted one chair built as fast as possible with their team color specified along with perfect functionality and aesthetics; how fast could you build it and what would be the progressive steps to build it – ASSUMING A MILLION DOLLAR ORDER WOULD BE PLACED BASED ON YOUR RESULTS?”

Chris told me, “No problem, we could do step A, then B, then C, then D, then E – moving immediately from one step to the other without interruption; we would have to leap frog all this inventory (waiting) but each station would be ready and able. We would need to have quality assurances at each operation and not wait until inspection. This line would produce a conference chair in a half hour.” Most importantly, Chris said, “I know we can do it.”

Up until this time, because of all the waiting, racking, hand-offs, queuing on conveyors, and stacks of parts, it took over 2 days just in assembly to complete and took 20 days total from warehouse picking to finished goods to complete a conference chair.

That afternoon, Chris and I with three people from the line, reduced the footprint of the line by 75%, got rid of the in-process inventory racks, and started the next morning assembling chairs in less than 30 minutes – with improved quality! Sure, we stubbed our toes almost immediately realizing the line was unbalanced but we were experimenting, learning, and never going back. It was liberating.

So, when I read about “…the Governor on the Stretcher”, I knew I had seen the equivalent of Chris' million dollar chair. It is best to quote Going Lean directly for a few paragraphs.

“The ambulance arrives. The trauma team is ready. Blood samples are drawn and sent by courier to the lab, where technicians are standing by. The trauma team's leader orders an x-ray, so the patient is rolled directly to the x-ray department, where technicians and a radiologist are standing by.

Exploratory surgery is ordered; surgeons, anesthesiologists, and surgical nurses are standing by. A surgical theater is cleared and prepped. Post-op space is freed up, the intensive care unit is standing by. Meanwhile, the admissions department is told to retrofit insurance formalities as the case unfolds. A skilled nursing home, a rehabilitation hospital, and a home nursing service are put on notice to stand by for later information and be ready to accept the patient.

All utterances of the patient's attending physician are transmitted in real time to the medical transcription service, to transcribe on the fly and to return for signature. The same goes for nurses' care plans and reports. Discharge orders are prepared in advance, including take-home instructions for medicine, therapy, and follow-up care. An ambulance is ordered to stand by for the earliest possible discharge of this precious patient.

Oops! It Isn't the Governor After All!”

From this provoking example, the difference between how the governor and the average citizen is treated is not the quality of care, it is the time it takes overall flowing (or not flowing) through the Health Care Delivery System.

If I really want to dig where the gold is, I had better observe and shadow patients' total experience through the current system – picturing them in the future as a governor in a million dollar chair.