Enhancing Patient Care with Lean Principles: The Chugachmiut Story in Alaska (Part 2)

LeanBlog Podcast Episode #71 is part two of a conversation with Patrick Anderson, the Executive Director of Chugachmiut, the Tribal consortium created to promote self-determination to the seven Native communities of the Chugach Region. I met Patrick at a Lean conference where he shared their experiences with applying Lean principles to healthcare delivery in Alaska. I am happy to bring their story to you, and here's the link to Part 1 if you missed it (Episode #53).

You can also read more about Lean concepts at Chugachmiut on their website. In this engaging episode of Lean Blog Interviews, we discuss the transformative power of lean thinking within the healthcare sector. Our guest shares their unique experiences from Chugachmiut, showcasing the integration of lean principles into both administrative processes and direct patient care. Listen as we discuss the benefits of creating a unified organizational culture, overcoming common challenges in lean implementation, and the measurable outcomes of these initiatives in enhancing healthcare delivery for native communities in Alaska.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.

Episode 71 Key Points and Links:

• About the Chugachmiut organization and tribes
• “A fact-based, non-judgmental, no blame, no shame culture”
• There are patients who are dying needlessly because of good people working in bad processes.

Questions:

• How do you characterize progress in terms of results? How would you measure the results you've had so far with Lean over the past four years? What kind of results would you expect in the future, either in regards to patient care, employees, or the organization itself?
• It sounds like you're taking a really good long-term and systemic view–not just measuring short-term results of existing processes, but really freeing up time and capability to provide better care and preventative medicine. Did I summarize that correctly?
• Can you talk about how the changes you've made have allowed you to focus on more strategic, wide-ranging initiatives?
• What have been some of the biggest challenges you've faced in implementing Lean, particularly in a healthcare setting, and how have you addressed them?
• How did the transition from a fact-based, nonjudgmental, no-blame, no-shame environment help reduce internal politics and improve your organizational focus?
• How are you integrating Lean principles in working with other parts of the Alaska Native Tribal Health System, and what progress are you seeing in that collaboration?
• How do you see the long-term impact of educating children on stress management, behavioral health, proper nutrition, and exercise on the future of healthcare in Alaska?
• What advice would you give to other healthcare organizations looking to adopt Lean principles, especially when dealing with resistance to change?

Automated Transcript:

Announcer:
Welcome to the Lean Blog podcast. Visit our website at www.leanblog.org. Now here's your host, Mark Graban.

Mark Graban:
Hi, this is Mark Graban. You're listening to episode 71 of the podcast for August 10, 2009. This was recorded late last year in 2008, but it's a continuation of episode 53–our discussion with Patrick Anderson, the Executive Director of Chugachmiut, a tribal consortium created to promote self-determination for the seven Native communities of the Chugach region in Alaska. Among other things, they provide healthcare services, which is the focus of our discussion here–using Lean thinking and culture in both administrative and care delivery processes. Today, Patrick will talk a lot about the culture of an organization and values, how Lean fits in with that, and how it helps them improve their delivery of patient care. As always, I want to thank you for listening.

Patrick Anderson:
Okay, final question–talking about culture, management system, and the progress that the organization has made. How do you characterize progress in terms of results? How would you measure the results you've had so far with Lean over the past four years? What kind of results would you expect in the future, either in regards to patient care, employees, or the organization itself?

You know, that's the toughest question to answer. In my faculty days, it would take four or five sessions to teach, Mark. So I'm going to try to be brief, but also expansive enough to convey my learning on that part of what you asked for.

The biggest problem one has is employee resistance. In most organizations, when you come into the job, you're not oriented properly. A lot of times I've come into a job and they don't have a desk for me. It takes two, three, four, or five days to find a place for me. Then finally, they'll maybe orient me to benefits, and then you're expected to learn the job on your own because there are no systems defined, and no one can break out the standard work to begin explaining how you fit in, what your role is, and how you should do things.

That was the biggest problem that I had. Chugachmiut was built upon individual effort and motivating people to perform individually at their highest levels. But that meant they weren't looking for opportunities to cooperate in processes with other people. They just wanted to make sure that when the work came into their hands, and when it left their hands, it had their highest individual quality of work possible. They didn't know, understand, or care that the whole end result of that may have been to add to the number of defects and the amount of time it took for that process to happen.

Sure, I had what I've learned are referred to in the trade as “concrete heads”–people who will tell you all kinds of wonderful things to your face, but make no attempt to understand. They basically figure that the average tenure of a CEO is probably four or five years, and they'll outlast this one and just keep doing things the way they've always done them.

Well, I came out of a successful law career and transitioned into nonprofit management because of a couple of nonprofit issues I wanted to address in the United States, particularly restoring responsible fathers back into the lives of their children and promoting healthy relationships. As a divorced father, I understand that there are ways to make relationships healthy. So I came into nonprofit management with a mission, and that mission had to focus on the people that we served. That was a big change in and of itself.

I had employees who were comfortable doing things the way they'd always done them. They would respond when you go in and exhort them for a little period of time, but then they'd outwait the managers and revert back to what they were doing beforehand. Without any transparency in the organization, you never really know where the defects occur. That's a common problem in all non-Lean organizations.

I did a couple of things that have taken a long time to filter through the organization. The first was to instill a sense of values–creating a corporate-wide culture of ethics, morality, and how you should participate in a social sense in the governance of your community. Then there are individual values, like: “I'm paid for a seven and a half hour workday that starts at 8:30 and ends at 5:00. My personal sense of value tells me that I'm going to give a full day's worth of work for that full day's worth of pay, that I'm going to be honest in how I use company resources, that I'm going to be honest in how I interact with the people we deal with, and most importantly, that we are going to work to benefit the people we're here to serve.”

Getting that customer focus meant I had to display it day in and day out. I had to speak about it frequently, and we had to write it into our policies and procedures. Most of all, we had to emphasize it anytime we dealt with value streams, ensuring that at some point the customer enters our stream of service and at some point they exit. In between, we need to make sure that the service they're getting is the absolute best we can give–not the absolute best ever, because otherwise, you have no room for continuous improvement, but the absolute best we can give. And then, when we discover defects, we're going to improve that service even more.

Those were difficult lessons, but we proceeded with them as we began to analyze the workplace. In administrative Lean, in 2004, there were darn few examples. We could look to the manufacturing industry. Even I, just sitting on the board of the plastics plant, could walk into a factory, into a plant, and immediately see the waste or the muda that exists. I could probably go in and lead a pretty competent Kaizen and have some decent results by the end of the week.

In administrative Lean, a lot of what you see is invisible. A lot of things that happen, you actually have to take out the stopwatch, break out the Post-it pad, and follow that, but you can't usually do it because lots of times the value stream can be, like I mentioned, with our hiring processes, 144 days long. So you find a lot of inboxes that you have to look at and a lot of other work that those individuals are doing because of their intersection with a whole bunch of value streams. It's complex.

We didn't learn a lot of that upfront, but we still managed to conduct a number of Kaizens. What it told us fairly immediately is that most of our systems were really bad. Our document management system, the absolute lifeblood of everything we do as government contractors, was severely broken.

You asked about measurement. We didn't know how to measure an administrative environment other than by isolated parts of it. When we started our document management system, we did take measurements of the amount of paper we had in the organization, which was a lot, but we didn't measure the amount of wasted time spent looking for lost documents, recreating lost documents, or transporting those documents. I sure wish I could go back and do that measurement, but I realize now that I couldn't have done it in the beginning because we were so poorly run. We were fighting fires all the time, and I didn't have enough staff time to do those measurements.

So we started a central records management system, and it was a godsend because we began learning about the transport part, about the accessibility part, about one-piece flow, and making sure the documents were there when you needed them. It also stretched our strategic vision, and we began to realize that with the improvements we were making, even having paper documents was waste. We are poised right now, through the selection of a new finance and accounting enterprise resource platform, to go digital for all of our finance records and then all of the other records. Beyond that, it's very easy to scan and store digitally. In about six months, we should be a completely paperless office. The changes in that are just incredible. The elimination of our accounting staff having to track down signers for checks is going to save days and days of labor every month.

The same thing applies to our IT. Most companies don't want to invest in IT, but we changed our thinking to realize that IT is a tool, and if people don't have good equipment, it can cause a lot of waste. The example I used at the Lean Healthcare Conference in Nashville had to do with my HR manager. The little example I cited was just the amount of time it took her to save documents in an antiquated system using fully depreciated equipment. It was two and a half days for one employee every year, and I had 60 employees at the time, probably 45 or 50 of them, who had to save documents. So that's practically a man-year worth of labor.

What we found, Mark, is that after our first year, we had freed up enough time to begin dedicating more effort to some of the strategic initiatives that also paid back the investment in increased productivity and increased service to our customers and clients. We had some real challenges, including resistance from my healthcare team to some of the improvements. I had five mid-level practitioners quit on me, and it took a year to replace them in a reorganization. That was stressful, particularly for my human resource staff. But as the changes have come into place, what we're finding is that we're focusing on our customers, we're providing more services, and we have a communication strategy driven by a wellness and prevention program.

In fact, the reason I told you that I had to wait until this time is that my healthcare division staff is now working on a planned care strategy with the Indian Health Service. We have a weekly teleconference where we discuss some

of the techniques that have been tried, and we then devise our own experiment on how that can fit into our practice. We now have the resources to actually fund the research, committee work, training, and implementation of an electronic health record. Our grant writing has improved so much that right now, we have a pretty significant grant to implement a more aggressive telemedicine system that will integrate behavioral health. The work we did qualified us to be one of the key partners for the University of Washington in a depression screening protocol that has been tested in non-Indian country but is now being tested through Chugachmiut in Indian country. We're going to bring screening for depressive and anxiety issues into our primary care center. We're going to structure a brief intervention, and hopefully, that will help improve the quality of life for our patients. Some of the results from the screenings done in non-Indian country show that some patients with chronic conditions have reduced the days they suffer from debilitating depression by as much as 100 days a year.

So we're thinking futuristically, and we have the time to address, research, study, and participate in a lot of initiatives because we're not fighting the fires we fought before Lean came into our corporate existence.

Mark Graban:
It sounds like you're taking a really good long-term and systemic view–not just measuring short-term results of existing processes, but really freeing up time and capability to provide better care and preventative medicine. Did I summarize that correctly?

Patrick Anderson:
You summarized it very well. Not only are we looking within our own system, but Toyota has paid extreme attention to its supply chain. As I mentioned earlier, we rely on the Alaska Native Medical Center and the Southcentral Foundation for a lot of our services. About two and a half years ago, I started advocating for the Alaska Native Tribal Health System to begin using process management, particularly Lean healthcare. We're getting some traction. You'll probably recall the discussion about St. Joseph's Hospital in West Virginia and the fact that they were able to double the amount of time that their nurses spent with patients just in one week of Kaizen. I used that example with the CEO of the Alaska Native Tribal Health Consortium. I've been leaning on him for quite a while to begin the process of converting the tribal health system management to a Lean management style. He is familiar with the Institute for Healthcare Improvement's initiatives on Lean, although I think he has a lot to learn. But he's willing to learn, and I think our system is going to work. But that comes out of my staff doing the work and freeing me up to be involved in the greater statewide tribal healthcare system and to begin to advocate for the adoption of Lean management methods within the institutions that we have to deal with. I'm excited. I'm really excited. I think the trend is happening in Alaska.

Mark Graban:
Well, that's great to hear, and it is exciting. It sounds like the time you're freeing up by not giving people the answers and dictating solutions is what allows you to work on these more strategic, wide-ranging initiatives.

Patrick Anderson:
Yes, that and mediating arguments and disputes among staff based on their political perceptions. When we went to a fact-based, nonjudgmental, no-blame, no-shame environment, the politics stepped out of the equation. Now, we're focused on what serves the patient, what is scientific, and what can we prove. We have a long way to go in measuring performance, but like I said, we don't have many examples in administrative Lean. We do have some in Lean healthcare, but a lot of those are hospital-related, which don't really fit our clinics. But we're also realizing that while we need to be knowledgeable about day-to-day process management, the big gains in healthcare are going to come from our children. If we can educate them on how to build a stress-free life, how to deal with behavioral health issues early on, proper nutrition, and good exercise, the healthcare system will be incredibly transformed in 15, 20, or 30 years when those individuals start using the healthcare system. In the meantime, we need to figure out how best to help our chronic care patients learn about their issues and adopt some of the same solutions–good diet, exercise, good hydration, reduction of stress–all while dealing with their behavioral health issues. Their quality of life will go up. So those are the measures that we're finding important now, Mark, not necessarily the day-to-day process improvements, which are becoming second nature for us to document.

Mark Graban:
Patrick, I can't thank you enough for taking the time to talk with me and the listeners. I'm really glad I had the chance to meet you at the Productivity Inc. Conference and that you were willing to share your story and your progress there in Alaska.

Patrick Anderson:
Well, I view this as a mission, Mark. There are patients out there who are dying needlessly because of a system in which we have fantastic, well-trained, well-meaning people, but they're working in very bad processes. I've just seen how much working on process management can improve the ability of an organization to meet the needs of patients. I feel that, probably like you do, I have to preach that particular gospel because people are dying when they don't have to.

Mark Graban:
That's very true. Good luck with your continued efforts, and I'm sure your words and thoughts here have inspired some others to take action. I really appreciate you taking the time.

Announcer:
Thanks for listening. This has been the Lean Blog podcast. For Lean news and commentary updated daily, visit www.leanblog.org. If you have any questions or comments about this podcast, email mark@markgraban.org.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.