Lean in a Liverpool Hospital

Follow Royal’s example on waiting lists, hospitals told - Liverpool Daily Post.co.uk

Nice story from here in the UK (where I am right now), about an NHS hospital in Liverpool reducing surgery patient backlogs and delays through Lean. From the article:

Surgeons, nurses, porters, managers, anaesthetists and admin staff got together to think of ways to shorten the patient journey for orthopaedic surgery at The Royal Liverpool Hospital.

This meant the number of planned operations taking place within 18 weeks of referral improved from 35% in April, 2007, to 88% in March, 2008. The number of patients waiting over 11 weeks for in-patient planned treatment fell from 261 to nine.

Theatre start times before 9am have been improved by 20%, and total cancellations have been reduced by 7%. Patient cancellations have been reduced by 30%.

The hospital has been working by the Lean method, which eliminates waste and improves efficiency.

Sounds like some nice teamwork and improvement. I'm nit picking on the reporter, but to give credit to the people at the hospital, the Lean method doesn't do anything. It's people using the Lean method, their drive, their leadership, and their creativity that eliminates waste and improves efficiency.

I'm hoping, in the future, I'll be able to publish or write about some of the work I'm doing over here.

I do have another publication coming out this summer, co-written by a colleague, about some Lean work at a hospital in Ontario, Canada. That will be in the Society of Manufacturing Engineers Lean Yearbook 2008. I also contributed a piece to the SME 2007 Yearbook, which can be ordered here. When the 2008 book is available, I'll post about it here.

So back to the main point... Lean really is universal -- across industries, across continents, and across cultures. It works! Or, I should say, the people make it work!

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A Very Non-Lean ER Experience

Thanks to a Lean Blog reader, Matt, for sending this first-hand account. I'm sorry he (and his wife) had to go through this experience. This is posted with his permission. I'll buck convention a bit and put my comments in the quote boxes. Matt's text will appear as the normal font below.

--------------------------------

Saturday night I had to take my wife to one of the local ERs. We got there at 9:40pm. When we got there, I filled out paperwork to register her with all the basic information (name, symptoms, SSN, address, etc…….). Then we had to sit there and wait……..and wait…….and wait. This was especially frustrating since my wife was curled up in the fetal position in extreme agony and no evened seemed to care.

Mark: This is sadly reminiscent of this episode at an LA hospital, but Matt's wife survived the E.R. encounter, in this case thankfully.

The maddening part was there was no privacy (except chest pain). Everyone else in the ER had minor things (sprained ankle, minor headache, etc……..). After we checked in a mother with a baby that could not have been older than 1 came in. The baby was green! It freaked me out. It was the one person I thought should get bumped in front of us, but they didn’t. They waited in the FIFO line too.

After 3+ minutes we got called into the triage room where about half the questions got asked again that were on the sheet I filled out. I found this frustrating since the data from our registration sheet was put into the computer and that is how triage got our name and called us in. Where did the rest of our data go? Why ask again? The triage nurse said this was part of registration.

Mark: This is a very common waste seen in E.R.'s -- definitely the waste of overprocessing, or a defect in the process that you have to repeat yourself. There's a minimal amount of repeating that's necessary to confirm they are looking at the right patient, but I'm sure some of the information just didn't get passed along. That's something many E.R.'s that work with Lean fix, only asking for information once, instead of multiple times. It saves employee time and causes less frustration for the patients. The nurse obviously doesn't feel too empowered to "kaizen" her system... just doing her job.... what can you do about it? That's a sad attitude to see, the culture creates that mood.

Then we went back out into the waiting room and waited for another hour before they called us back. As they were taking us back they stopped me and said that I had to register to go back with my wife. I had to register at the same desk as the first registration an hour and a half earlier. So, my wife is in agony and can barely walk and I have to stay up front and to have my ID scanned and a sticker badge given to me. Then I get let in and I have to search for her room. I finally find her and we wait for a third person to come in and ask the same registration questions again. She is even wearing a badge that says “Registration” on it. My wife asks why this wasn’t done in the waiting room where we have been for that last 1.5 – 2.0 hrs. The lady replies that “this is just the process.” We could’ve had all the registering done in the waiting room up front. This seems to be a little more batch (“batching all the paperwork up front”), but I would argue two points: 1. there isn’t as much batching as one might think because we are getting all the same questions over and over with a couple of new ones, and 2. this would be more customer focused because my wife is in pain and we wouldn’t be separated plus she wouldn’t be getting upset about answering all the same questions over and over again. At this point, my wife looks up an me and says, “This isn’t very lean is it?” I was glad to see her smile through the pain.

Mark: Matt and his wife made the point perfectly, so I won't elaborate much. Matt should have been able to register while they were waiting. Again, there's more of that "well, this is just the way it is" attitude from the staff. That's something you would have to work on during a Lean implementation, convincing people that they actually can work at improving the system, not just accepting it for what it is.

We wait for a long time and finally see a doctor who orders a CT scan, so we wait for the scanner to be setup and then we wait for the results and then we wait for the doctor, etc…………..

During all this waiting I speak with some of the nurses. At this point it is about 1 or 1:30am. The nurse tells me that this is a real slow night. Usually the halls are lined up with patients. I notice that they can’t find their electronic thermometer and go borrow one from another area, the supply area is labeled but is very messy and can’t tell how much is suppose to be there. The nurses can’t find things and quite a few times are just sitting around talking about their lives outside of work. They spent a lot of time doing this. Not because they don’t care but because they are waiting on doctors and information and whatever they need to treat the patients.

Mark: So there are 5S and organization issues... people can't find things, that leads to wasted motion and waiting time. Again, very common. The idea of people just sitting around and talking about their lives.... sure the nurses might have waiting time (waiting on others), but you can also see the opportunities to use that time for kaizen. Or, if you reduce waiting time and improve the flow of work, the nurses are going to lose some of that watercooler time. Then, will they perceive they are "working harder" or will they be happy that they can spend more time on direct patient care (the "Value adding" work)?

The most disheartening thing I heard all night was about a computer. I heard that they had test results back on the baby that was green (and I literally mean green) but nobody has been able to view them for an hour. They were having problems getting the computer to work so they called IT. There was no manual override or way to get results so the baby couldn’t be treated until they got the computer working. WHAT!!!!!!!!!?????????? I couldn’t believe what I was hearing. I don’t know what happened to the baby and the test results but I hope everything turned out alright.

Mark: There definitely should be a backup plan or a manual process for getting that result. Worse case, they should have been able to go to another PC, unless their whole information system was down. Even then, they should have been able to make a phone call to the lab to get those results. I wonder if people didn't know the backup process or if they were too busy to take those extra steps.

At 2:30am, we finally left the ER with pain medicine in hand nearly 5 hrs after walking in the door. I figure only about an hour was value added. This house is being generous too because it includes the walk time to the CT scan and the 20 minutes we had to wait after receiving the pain meds before we could leave.

Like you have said, the doctors and nurses were great people and wanted to help. The systems just sucked!!! I was thinking about lean stuff all night and trying not to blame the people but at times I would even find myself getting upset with the people “just sitting there” and not helping. My emotions would just take over as I watched my wife in pain.

I have always believed that lean is for everyone and every place because it is the mindset. Saturday night was just one of those “hit home” experiences that brought it to light.

-----------------------------

Matt, thanks so much for sharing that experience. That scene is repeated many times over every night. This shows how difficult it can be to NOT blame the individuals working in the system. Sitting around and chatting about home or Dancing with the Stars is just a symptom of systemic problems. It takes leadership to solve situations like that, and Lean can help. The good news is that Lean IS helping, we just need more of it, at hospitals like the one Matt and his wife went to.

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Your Dermatologist Might Not be FIFO

Patients get appointments for Botox faster than for moles: study

You might expect that a doctor's office either takes appointments in terms of:

• FIFO (first into the queue, first out -- first called, first seen) OR
  
• Triage priority (more serious or time critical cases first)

Here's an article with a study that suggests that some dermatologists are giving expedited priority to high-profit Botox customers over those who have concerns about potentially deadly skin cancer.

"The study was conducted last year by telephone with researchers posing as patients, contacting 898 dermatologists in 12 US cities.

In Boston, for example, the median wait for a Botox session was 13 days while it was nine weeks for an examination of a changing mole."

This was repeated in multiple cities and the study author said:

"It was possible doctors wanted to offer faster access for Botox treatments "because of higher relative payments for cosmetic services," the study said."

You might understand Dell choosing to build a huge order of expensive PC's first over a few smaller orders for a single $399 PC.... that's profit maximizing. But, as much as healthcare likes they say "they're different", this seems like once case where they are NOT different, and maybe they should be.

What do you think? I assume we have mostly patient perspectives here...

Suboptimizing an Australian ER

'Surgery should be halted' to clear hospital backlog

Sub-optimizing decisions are a fairly universal human behavior, regardless of the industry (or continent). Lean teaches us to look at "value streams" that go across departments and to view operations from a "systems" standpoint, looking at the complexity and the interconnections the best we can.

In the article I've linked to, an Australian hospital has a pretty common problem -- the ER is full because they're having trouble getting patients into rooms, the so-called "boarding" problem where patients are kept in the ER longer than they have to. It's a systemic patient flow problem that goes across departments. It might be an overall hospital capacity issue, it's sometimes a process issue where the discharge process is inefficient and inpatients are kept in rooms longer than necessary, thus backing up the ER.

When the ER is full, the hospital can't accept more ambulances. It sounds like, in this case, the patients are kept waiting in the ambulances, which is bad for the patient and it ties up the ambulance resources.

"A specialist in emergency medicine says hospitals in south-east Queensland should stop elective surgery for up to a month to clear a backlog of emergency cases."

Think about that for a minute. To solve the ER problem, you're going to STOP doing elective surgeries? That seems like a "solution" that a specialist would come up with -- concerned only with their own department, the ER, apparently.

What are they going to do to solve the elective surgery queue that would grow by one month??

We need systemic solutions to problems like these. Easier said than done, but Lean methods are having a huge impact with hospitals around the world.

Here's a longer article on the same story. Here, it claims the doctor is asking for a "two day" stoppage on elective procedures. That's better than a full month, but still isn't getting to the root cause of the patient flow problems.

Dr Knox said although stopping elective surgery was not a long-term fix, the situation needed a circuit-breaker.

"If you stopped elective surgery for two or three days, you could then clear emergency departments and let them recover," he said. "I think that's the only immediate solution."

At least he realizes it isn't a long-term fix. The queue would eventually re-form if the flow isnt' balanced.

Press "1" If You're Hurting in English...

Parkland Hospital Deploys Galvanon's MediKiosk(TM) in the ER to Decrease Patient Wait Times

It's been discussed here before, how hospitals are just as susceptible as manufacturers are to the "Siren Song" of technology. This time, it appears Parkland Hospital (here in Dallas) is presenting with such symptoms...

You might know Parkland as the historic hospital JFK was taken to after being shot in Dealey Plaza. It's still open as the large county hospital for Dallas County. I presume they have long waits for ER treatment, as is common in hospitals. Many hospitals are taking the "Lean" approach to reducing waiting times in the ER. Strategies I've heard recently about include:

• Changing the "triage" process so patients are seen immediately by an MD -- providing more accurate assessment than an RN could with the added benefit of reducing the need for a patient to repeat the same story to multiple people.
  
  
• Separating the ER into two separate "value streams" or "patient pathways" -- patients who will be treated and sent home versus those patients who are likely to be admitted. A hospital in Australia implemented such a process and started seeing patients in each stream in a "FIFO" (first-in-first-out) process that cleared up delays immediately.

The Lean hospitals are fundamentally rethinking the process, not just automating parts of the process. Parkland went the technology route:

Parkland Health & Hospital System, based in Dallas, recently launched self-service check-in kiosks in the emergency room to speed the delivery of care and streamline registration processes. The technology, called MediKiosk, is provided by Galvanon, a subsidiary of NCR Corporation (NYSE:NCR).

So, basically, you have the "option" of pushing buttons on a glorified ATM machine? This is considered an advancement in healthcare? I'd think not, it certainly doesn't seem very "Lean" at first glance. This article claims Parkland is the first to implement this system. Do we want to see others? Here is the MediKiosk website with their PDF brochure (with pictures)

Three self-service check-in stations in the Parkland emergency room triage area offer patients the option of interacting in either English or Spanish. Instead of waiting in line to explain their symptoms, patients can identify themselves at one of the kiosks by entering their name, along with an additional identifier, such as a birth date. Patients then use the kiosk’s touch screen to identify their symptoms by pointing to areas on a body diagram where they feel pain and answering brief questions about the nature of their visit.

What amazes me is that this "innovation" is referred to as "more comfortable" and "less stressful" for patients.

I'll go out on a limb and say what we need are real patient flow improvements, using Lean methods, instead of throwing technology at one part the problem.

I'd be curious to get involved and ask "why" patients are waiting to be seen at the ER. Is triage really the bottleneck? Is a computer system cost effective compared to adding more people? Is it more humane? Is the ATM more effective?

Rather than throwing resources (ATMs or people) at it, can we streamline the process so triage can be done more effectives? Better yet, let's question if triage is really necessary... the goal isn't efficient triage, it's improved care, improved patient outcomes, and reduced waiting times. I'll be curious to see if there is a press release bragging about the actual results of this new technology...

Lean, No Wait ER's

U.S. hospitals try to pick up the ER pace - Yahoo! News:

You might have seen this sad case of a fatally broken ER on the news over the weekend and I have more comments on that later.

On a more positive light, "about a quarter" of U.S. emergency rooms are working on "no waiting" or "30 minutes or less" goals:

"Some hospitals are moving to eliminate waits altogether. The Adventist GlenOaks Hospital in Illinois promises no waits at all. As of last week, patients could skip the waiting room and go directly to a private room where treatment starts as registration is done bedside."

The article doesn't explicitly mention Lean, but the process change shown above could come through a Lean process. Lean never says "do stuff faster," whether it's a factory or a hospital. Lean thinking pushes you to take out waiting time by CHANGING the process.

As Deming said (I might be paraphrasing), the last thing we need is everybody trying their hardest as part of a bad system. We need to change the system, this is good for the patients, the employees, and the hospital.

That will be one of the major themes in my upcoming book, "Lean Hospitals." The book is underway, I'll post my progress as we go (and my writing actual vs .'takt time'), stay tuned.

Moving the ER 10 Miles Away HELPS Flow?

The Cincinnati Post - St. E's plan for ER is unique

Thanks to blog reader Karthik for sending this my way. I've read the article three times looking for something positive to say and am still struggling.

The headline says the plan is "unique." If you're the only one doing something, it might mean you're brilliant... or you might just be the only one doing something.

St. Elizabeth Medical Center's plan to move the emergency department from its North unit in Covington to a standalone, ambulatory care center about a mile away is apparently a first in Kentucky.

An ER expert (I'm certainly not one) says:

"That's weird," Dr. Michael Bishop said. "They'd better have a monorail that runs from the ER to the hospital."

The Bloomington, Ind., doctor has managed emergency departments for 35 years. The American College of Emergency Physicians considers him an expert on emergency rooms.

He said he had never heard of a hospital that closed its emergency department and moved it off-campus.

"Even within a hospital, it creates problems if the surgery is too far from the emergency department, or if radiology is not right next door," he said.

"I'm sure it will be a good emergency department, but after that first hour, they've got to go somewhere else."

Seems crazy, eh?

My Stack of Books: Raw Material and WIP

I love books. I'd also love to have more time to read books, or finish books. People often ask me what I'm reading. Here's what I'm trying to read or am wanting to read:

"WIP" -- started, but haven't finished (doesn't mean I don't like the book)

• Getting the Right Things Done
• Leadership for Smooth Patient Flow
• Managing the Professional Services Firm
• Errors, Medicine, and the Law
  
• The Health Care Value Chain
• The Baptist Health Care Journey to Excellence

"Raw Material" -- books that are sitting here, but haven't started (in order I'd like to start them):

• Better: A Surgeon's Notes on Performance
  
• Evolving Excellence
• The Strategos Guide to Value Stream & Process Mapping
• The Gold Mine (sent to me for review)
  
• Value Acceleration (sent to me for review)
  
• Lean for Dummies

Ah, the waste of overproduction. My head tells me it is waste to buy books faster than I can read them, but I can't help it.

We're all busy and don't have enough time, especially with so many good lean books coming out on the market. Maybe we need a lean book summary service, along the lines of those business book summary clubs?

What are you reading, or waiting to read? What's in your book inventory that hasn't been converted to "finished goods"??

A note on the Strategos book. There's an endorsement quote from me on the back, I did look at an electronic preview copy, so I've sort of read it, I guess.

BBC Radio Program on Lean Hospitals

BBC - Radio 4 - In Business

COMING MID 2008, A NEW BOOK ON LEAN HEALTHCARE - "Lean Hospitals: Improving Patient Safety, Quality, and Employee Satisfaction," by Mark Graban

Here is a nice program from the BBC, can listen in streaming audio or it can be downloaded. Go 1 minute in from the start of the file, as the first minute is apparently the end of the previous program.

The host visits an NHS hospital and focuses on some of the work done by the UK Lean Enterprise Academy and Dan Jones.

The program provides a nice overview of lean concepts put into use in the hospital.

About half way in, there's a great quote about patient waiting time, I'm paraphrasing:

"The queue is to healthcare today what it was to manufacturing in the 1970's.... the queue was an asset that allowed you to keep employees fully utilized. But, the downside is that the queue is incredibly stressful and it costs a lot to manage, wasting resources and wasting people's lives."

I've seen that dynamic first hand. The doctor is usually the high-priced asset that needs to be utilized, so we keep it busy by building up "WIP" (work in process) inventory, in this case, it's people.

About 21 minutes in, the host takes us back to the hospital emergency room, two months after the week long kaizen event ("rapid improvement workshop") had taken place. The reviews were actually somewhat mixed:

A doctor, the director of emergency care, who had helped organize the event said (I'm paraphrasing):

"Perhaps we didn't do enough groundwork before hand in terms of bringing the department with us, so they understood what we were trying to do and that we were really there to help them. When you say lean manufacturing, it depends on to whom you use the phrase... some still won't have gotten what we were trying to do that week."

This is one reason why I don't think a kaizen event (or many kaizen events) will make any workplace "lean." You have to involve employees, and that takes time. Truly changing to a lean culture takes time. A kaizen event can't do that, I think, so in a way the doctor's response doesn't surprise me too much.

The host also talked with a surgeon who had been on the kaizen team:

"I thought it was very useful, an eye opener... during the course of the week, it was obvious we could apply these ideas to make work flow better. But, there were pockets of resistance along the line, people were protecting their territory... we need people to understand change has to take place."

That's the role of leadership, to help create the pull for lean methods.... to get people motivated that lean will benefit the patients and to help eliminate the fear that might cause employees to think lean would hurt them or end up costing them their job.

The consultant said that the hospital needed to come up with a way to make lean a program, after the two "experiments" with kaizen events, to create a "lean team." That's what the consulting organization I'm a part of does, we don't do flashes of kaizen events, we actually train employees to make lean changes as an on-going effort, and to coach managers and leaders how to sustain it, not as an "event" but as a way of doing things every day.

The consultant also said (and I agree with her on this) that the kaizen event is just the first step on a long path toward lean. I hope the hospital (and the rest of the NHS) can get there.

The Lean Enterprise Academy has a healthcare page, which includes a nice whitepaper on applying lean to the NHS.

An Open-Access Doctor's Office

Business Week Article

Here's a good story about how some doctors offices are trying to reduce backlogs and appointment delays, by adopting lean and operations management methods.

As the head of a large primary care department at a Kaiser Permanente facility in Northern California, Dr. Mark Murray knew he had a problem. The average wait time for an appointment was 55 days, and even then, patients had less than a 50-50 chance of seeing their own primary care physician. On a personal level, listening to complaints from his dissatisfied patients was frustrating. And as a doctor, the situation made him extremely uncomfortable. "I knew that inside those 55 days there were mammograms that needed to be done, patients with chronic conditions that were getting worse," he says.

It sounds like the doctor had done like many manufacturers, going the technology and "work harder" route first.

During the 1990s, Murray tried everything from increasing overtime to centralizing the phone system, but nothing seemed to have any effect on the bottlenecks. He was responsible for 250,000 patients, 100-plus doctors, and 400 support staff, and nobody was happy.

That's when he realized that his problem was one the business world had solved long ago. "If you go to Starbucks, they don't ever say, 'we don't have lattes today, come back later,'" he says. "They have a plan to match their supply with your demand as quickly as possible. Why can't [health care] be the same way?"

Well, that's not exactly true. I heard a Starbucks counter employee, just this morning, tell a mother that they were out of stock on Vanilla milk that her son wanted. Even Dell stocks out on components and tells you, sometimes, that they can't build and ship a certain product to you today.

The article continues to talk about creating "same day appointments" to "do today's work today." The article discusses some simple spreadsheet tools that are used to help calculate how many patients a doctor (or office) should be able to see and how much doctor overtime will be required to see all of the patients.

This is definitely a big improvement over 55 day waits. Could we challenge the idea of "doing today's work today?" Since the starting point was 55 day waits, maybe the office could "level load" a bit over a two or three day period, reducing overtime while still dramatically reducing patient appointment delays? Reducing overtime might help improve quality of life for the doctors and their families.

Whatever the details are, it's encouraging that these types of practices are spreading:

Murray estimates that as many as 20% of primary care physicians are currently using open access, but for most Americans, getting a timely doctor's appointment remains a pressing concern. According to a study by the Commonwealth Fund, a health policy think tank, only 30% of U.S. patients in 2005 had same-day access when they needed to see a doctor, and 23% waited six days or more.

I applaud the doctors who are challenging the status quo for "how things have always been done." I'm going to be attending the Society for Health Systems conference in New Orleans next week, where I'll be able to learn much more about how doctors and hospitals are improving patient flow with lean.

Your Lean Year in Review

Happy New Year!

As 2006 ends, I hope many of you had a GREAT lean year. Please add your comments about your lean accomplishments for the year, or at least one key lean accomplishment.

I was very fortunate to do a consulting project with a hospital laboratory. In a 14 week project, we significantly changed the lab layout for improved flow, implemented 5S and visual management, put new "standard work" in place, started a kanban system, and worked on learning to manage in a "lean way." The team learned new problem solving methods (such as the "5 Whys" and started eliminating workarounds by fixing root cause problems.

It was just a start, but we reduced the lab Turnaround Time (lead time) by 35% without adding headcount while freeing up 250 square feet of space. Doctors (and patients) are more consistently getting test results on the patient chart on time for morning rounds (85% on time versus 60% on time), which makes them very happy.

The hospital is just starting their lean journey, in this department, and throughout the hospital. They know they are not "lean" and done after an initial project. They know it is an ongoing effort and a new way of operating. The beauty of the above results is that my client team did it. I helped, but I don't deserve all the credit (nor will I claim it).

For that, and so much more, I'm very thankful for 2006.

Ok Then, I'll NOT Wreck My Car

The consulting group I work for is a subsidiary of a very large company, with a large fleet of company vehicles. Driver safety is a major focus, both because it's the right thing to do (help keep employees safe) and it helps insurance rates, I'm sure.

We have a metric: "Accidents per million miles" (APMM).

Today, I get an email that shouts (I'll spare you the 42 point red font the email came in):

2.80
This is your 2006 Goal!

You have 23 days to be accident free!

2006 YTD Ranking (APMM) is 2.72 Great Job!

Stay Focused & Hit Your Number,...

Not Your Car.

(especially in parking lots)

A few points I think we can learn from:

I wasn't PLANNING on getting in an accident before that email arrived: I don't want to get hurt. I don't want to hurt others. I don't want to fill out company paperwork and deal with the aftermath of an acciddent. I would assume that NOBODY wants to get into an accident.

Does having a GOAL and communicating it help? Does this goal and metric motivate me to avoid accidents? I already wanted to avoid accidents. If someone turns in front of me will I slam the brakes harder or avoid the accident more deftly because I'm thinking, "Oh crap, our goal!!!" ??? This kind of email seems like a waste of time -- for the manager who wrote it and for everyone who had to delete it from their inbox.

If not having accidents is good, why isn't our goal "zero"?? I've seen factories set goals of injuring X number of employees per year. That's crazy. A good practice is to set a goal of ZERO. A hospital I recently worked with set "absolute" goals like this -- for patient safety, for not having to shut down the ER because patient flow was backed up, etc. I was happy to see that. Nobody wants to hurt an employee or a patient. Setting goals doesn't influence this behavior. If setting goals worked, our fleet goal would be ZERO accidents and we'd all work harder to meet that goal, right?

Imagine if there was a bonus tied to this metric? I'm surprised there isn't. Would I be more likely to avoid accidents if we all got a $500 bonus for being below our goal? What bad behavior and dysfunction might this drive?

Setting "expected" goals might be reasonable for planning purposes (based on previous years how many accidents might we expect?) but it's NOT the right goal for motivation purposes. When setting a goal, you always have to think about the behavior that is being driven by the goal. Don't count on a goal itself being motivating.

Rather than communicating about the the goal and metric, the only useful thing in that email is the tip to be careful in parking lots, as many accidents occur there and we're all likely to be at the mall and in a lot of parking lots this year. That's a good example of coaching to manage behavior (that will impact the metric) rather than managing to the metric.

Why "Pull" for Hospitals?

Before any of you give a knee jerk reaction about how "pull is good, push is bad" --- I agree with you... pull is better than push. For manufacturing. In a factory, a "push" system pushes production and inventory along so it just piles up and queues up regardless of downstream demand. A pull system, where operation A only produces what operation B can handle can keep WIP down, as long as operations are pretty balanced in cycle time and are always available, from an uptime standpoint.

I saw this question today in the "Healthcare Management Engineers" Yahoo Group.

We are in the process of building a new Emergency/Urgent Care facility. We would like to develop a pull system where it is possible. I am wondering if any of you have used lean methodology in your Emergency Departments. Were you able to achieve a successful pull system in the ED? How did you accomplish this? What were some of the strategies and tools that were used to create a pull system?

This seems like the internal hospital consultant is looking to use a tool (pull) -- it's actually more of a concept than a tool -- for the sake of using a tool... because pull is good, right?

What is the business problem being solved? I've worked with hospitals that have horrible patient flow. The emergency department is "boarding" patients, which means you're stuck in the hallway. Why is that? Is it the ER's fault? No.... there aren't beds available for you to be admitted into. The beds are full, or they're closed down because there aren't enough nurses. The ER is so full that the hospital is "on diversion", which means they aren't accepting ambulances except in severe life threatening emergencies. Bad bad bad. These are huge problems that we need to solve.

So is "pull" the answer?

With the current state.... we HAVE pull. The ER isn't "pushing" patients up to the inpatient units. They are only moving a patient when a bed is freed up (when a patient is discharged -- hopefully, they're going home, not here). Space downstream (bed) opens up, bring a patient from upstream (the ER). That's pull. And that's totally broken.

I'm not saying the ER should push patients to lay in the hallways of the inpatient floor instead of the ER.

What we need is the following:

• Balancing of capacity (beds) with demand (patients). This means having enough rooms, enough nurses, and making sure that we're flexible enough to put patients in rooms that aren't excessively specialized (having the "wrong" kind of rooms open).
• Standard work: we need predictable, consistent processes to make sure that patients are discharged without delay, thus freeing up beds for new patients.
• Flow: we need to reduce delays and waiting time between process steps
• Visual management: how does the ER know when a bed is open, so they can immediately bring a patient up?

There are a number of lean tools that I would think about using first before "pull." Looking to use any one lean tool, rather than solving the problems at hand, brings potential for ineffectiveness. It's a bad sign when I hear anyone saying, "how do I use this tool?" instead of "how do we fix this problem??"

You Can't Turn Customers Away, Can You?

STLtoday - News - Science & Medicine

This was sent to me by blog reader Joe. He was appalled to read about this and I understand where he's coming from. It's hard to understand that hospitals can throw their hands up and say "we're too busy" and turn away ambulances. The lean solution, the right solution, of course is to make sure you are flexible enough to handle whatever customers get thrown your way at busy times. You can't "level load" the ambulances that arrive at your hospital.

From the St. Louis area, a scene that's repeated far too often around the U.S.:

More than half of St. Louis-area hospitals turned away ambulances at the same time one night this year.

Dispatchers reporting patients with chest pain, seizures, stroke, gastrointestinal bleeding, pregnancy problems, abdominal pain and injuries from motor vehicle accidents were told to find another emergency room.

It doesn't take an industry expert or a lean person to point out that this is bad:

National experts say hospitals should not divert ambulances at all.

Diversions can be disastrous, said Dr. Robert R. Bass, an emergency room physician and president of the National Association of State EMS officials.

"It means ambulances have to travel farther, and that can delay care to the patient," Bass said. "It also delays the amount of time that an ambulance is out of service, and that means it is not available to other people in the community who might need it."

A recent Institute of Medicine report says there are only two reasons a hospital should divert an ambulance: a crisis within the hospital, such as a fire or power outage; or a mass casualty incident, such as a plane crash.

As I've written about before, it's not strictly an ER problem. You have to look at the "extended value stream", if you will. If the ER is backed up, it's often because the hospital has trouble getting patients admitted into rooms. Or, it's because they have horribly inefficient processes for getting patients DISCHARGED. You can't admit a patient if you can't get one discharged. When the rooms are full, flow in must equal flow out.

Hospitals often discharge patients late in the day or in the early evening, exacerbating the bed shortage.

Ah, a lack of level loading! Now there is a lean lesson. Many lean efforts in hospitals are focused on spreading out, or leveling, patient discharges throughout the day. This level loads the effort required by nurses and housekeeping staff. The level loading reduces the delay between discharging one patient and getting another one in.

"The patients haven't left their beds yet, but more are coming in," Larson said. "We run into this situation between 3 p.m. and 7 or 8 p.m., when we are in a crunch from both sides."

Years ago, when hospitals were 40 percent full, efficiency wasn't so critical, said Bass, of the association of EMS officials. But now that hospitals have reached occupancy rates of 80 percent and higher, it's important for them to get patients in and out efficiently.

80%. That number stands out because if you're an Industrial Engineer or if you've studied "Factory Physics" (the outstanding book by Hopp and Spearman, two of my professors from Northwestern University), you know that the waiting time or cycle time in a system tends to explode when utilization reaches 80%. Very crowded systems have long waiting times. You can't have 100% utilization of a resource (as accountants and cost thinkers would want) without long waiting times (the bane of lean thinkers).

The good news -- lean methods CAN help. Lean can't level load the arrival of ambulances, but lean CAN make hospitals more flexible in handling the demand that does come their way.

Amazing Single Piece Flow MD Office

MedQIC - Patient-Centered Care Supported by an EHR

The link above (and this audio-video presentation with similar content) tell an amazing story of a private practice family physician who has a "single patient flow" process in his office.

This doctor re-thought the entire patient process, from the perspective of a patient. He was inspired to do this after he had a lousy experience being a patient for another physician.

Imagine this sort of experience as a patient:

• You show up for your appointment and walk to the counter. You say "I'm here" and don't have to sign in or do anything.
• You are immediately walked to your exam room where an assistant takes basic information and enters it directly in their Electronic Health Record (EHR) system that's right there in front of you.
• On average, 63 seconds (SECONDS!) later, the MD comes in and sees you. The MD sees the information that the assistant took down so you don't have to repeat yourself. While talking, the MD takes notes directly into the EHR (while not really losing eye contact from you).
• When done, you walk to the front desk, where you wait, on average, 60 seconds to get a print out detailing your next appointment, lab work that might need done, and a printed (not handwritten) prescription.

On average, their "value added" time for a patient is 91% of time on site, 22:12 out of 24:24 overall spent in the office. The doctor isn't being "efficient" by being short with the patients and by rushing them through.

This is clearly efficient from a patient standpoint. The office's goal is to never have you sit in the waiting room.

This is also efficient from an MD standpoint. Dr. Griffin spends 61% of his time on direct patient care, and a total of 88% of his time in exam rooms, which includes doing the charting while talking to the patient. In most offices, the MD does charting at the end of the day, which has an impact on the quality of the notes that are taken. Taking the notes in front of the patient also gives the patient a chance to ask questions, which reduces the number of times Dr. Griffin is interrupted by patients calling back with questions. When the MD and patient walk out of the room together they are "just done" with no follow up work for the MD.

It's a great story. I love the one comment from Dr. Griffin -- it absolutely relates to the ideas of the book Lean Solutions:

"Respect for patient time is a business model."

I love it.

Two other great lessons and keys to Dr. Grffin running his office in this "lean" way:

• Engaged and committed staff - zero turnover in seven years
• Proper selection and customization of the EHR system -- selecting software that allowed Dr. Griffin to practice medicine the way he wanted.
  

These are both great lessons for lean in a factory setting. In far too many factories, the process is dictated by limitations of the ERP or MRP software. Dr. Griffin has it right -- design the process first and have software that supports your lean process.

Part of me is skeptical -- how can Dr. Griffin's appointment times be so predictable? What happens if Patient X takes longer than he expected. I'm sure some patients must be delayed once in a while. What happens with patients who show up late? But you know, most patients show up late because it's "OK" - they expect the MD to be running late anyway, it's a vicious cycle. I bet that when the MD respects your time, you the patient are more likely to respect their schedule.

Overcrowded ER killing patients

Vancouver Sun

The doctors are complaining publicly in Vancouver. It's a sad situation and I hate to nit pick or criticize.

"At least once daily, during a peak in patient load, 'the Emergency Department cannot handle the influx and has no consistent strategy to effectively handle the flow of patients,' says the hospital document.

It adds, 'there are areas within the department where no active treatment of patients is possible because of inadequate staffing.'"

This reminds me of the general human nature urge to complain "we don't have enough people." Maybe what's required is better processes and the elimination of waste and non-value added activity instead? People complain in factories and adminstrative processes, "If we only had more people." Well, if you did, you'd have more people doing non-value-added work and getting in the way. You might get some additional value add, but I think you're better off looking for waste first. That frees up true productive capacity.

Well a report has been written, that should solve it (sorry for the sarcasm):

This document reveals both the health authority and the ministry are well aware of the ER problems. The ministry has asked for quarterly status reports on progress toward resolving the ER decongestion.

The document sets out a detailed jargon-filled plan for future action, featuring a lengthy and complex list of objectives, time lines and accountability measures.

Jargon? Unless that jargon include our favorite Japanese lean terms, I'm worried about what they are really fixing. Maybe if they say "fix it now" and put pressure on people, what will fix it? That usually doesn't work. You really need to fix your core processes and institute lean thinking.

"Interventions and laboratory investigations are often missed or not done. Suspected cardiac patents wait for hours in chairs until their lab results come back, all the while at risk for sudden death."

Lab turnaround times like this (hours) are far from world class for cardiac testing. It's not just "the ER" that is the problem, as the headline says. The hospital lab is contributing to the ER delays through slow test resulting. As with many things in lean, the problems aren't always isolated to just ONE department. It's a complex system, the ER interacts with the lab, they are tied together in providing care. Most newspapers blame the ER because that's all they understand or that's all that readers will understand.

Good luck to you if you need an ER visit in Vancouver (not that this is the only North American hospital with problems!)

Pull issues in service

By Jamie Flinchbaugh, Lean Learning Center

For my first direct posting to LeanBlog.org, I thought I would jump right in. I get a lot of responses to my column, Leading Lean, which is in Assembly Magazine each month. I welcome those emails and thought I would respond to some of the questions here. My April column was about pull, and here was one of the responses I received:

How does pull work in a service business? Is a service business on the other end of this? In other words, a service business must meet the demand as it occurs. In a bank, for example, there must be enough tellers to meet the demand at different points during the day. Are there lean tools and concepts that help us to understand better how to provide excellent service without over-staffing?

There are two distinct concepts at work here. The first is pull in service and the other is leveling, or heijunka. Let’s deal with pull first. To enable pull in any process, I first need to achieve some level of flow. Without any flow, with forks and loops in my process and waits and delays, it is difficult to have successful pull. So first thing about flow. Pull in the simpliest sense is responding to consumption, whether it is a machine or a customer. Since I haven’t actually been inside of a bank for years, I’ll use another example. If a McDonald’s is operating well (which is a big assumption), the process for making hamburgers should have some flow from patties to toppings to wrapping to the customer. Now, consisder how McDonald’s tries to work. They work towards having pull at the end-unit level. They can’t make it just when you arrive, because you are only willing to wait about 2.5 seconds for your food before starting to grunt and groan with impatience. So they have end units, hamburgers, finished. Ideally, if they had a stock of 5 hamburgers, as one would be consumed, or put into a bag, that would indicate to the hamburger maker to make one more. It doesn’t always work this way, but that is the goal. The reason is doesn’t work is that there isn’t a clear, unambiguous signal to replenish. That’s all pull is – a clear, unambiguous signal. In service, consider what is consumed, whether it is time, materials, information, and how it is replenished or supplied. Then, is the need and the supply clearly connected?

The second concept this gets into is leveling the work. When you can achieve level work, a whole lot more waste can be eliminated, pull and flow work in a stable environment and capacity can be planned and minimized. However, our customers won’t always accept that leveling. In Toyota, this is the case, and Toyota is willing to either have excess finished good inventories or leave orders unfilled on the table in order to achieve level flow on the back end. In service, such as a bank, our capacity is directly linked to the customer order. When you have spot demand, you can not produce to a day’s average customer demand rate. Imagine if an emergency room said “we are designed for an average of one patient every 5 minutes, so you 40 people that just came in will have to wait.” Think about the other work that goes on. You might have to rebalance the work, cross-train and do some other things so that you can flex some resources. For example, one hotel used their deep cleans to fill the buffers on their slow daily-clean days, resulting in an level amount of work every single day.

Remember than in service processes, the lean concepts are not less applicable. They may be harder, but that is only because it is harder to see the process.

We're ALL Done With Batching?

I'm watching a web presentation on improving patient flow from the Institute for Healthcare Improvement (IHI). I'm doing lean healthcare work now and the IHI is an excellent resource, including Steve Spear, formerly of Harvard (and referenced by Mike Lopez earlier).

In the presentation, a medical doctor is talking about improving flow and reducing batching in the patient discharge process. He's generalizing, but he says:

"Industry no longer uses the batch concept. They no longer use the batch concept because it's inefficient, costly, and it doesn't take into consideration demand and capacity."

Well, I'm glad that battle has been won ;-) Many factories and managers in the industrial world are still addicted to batches and addicted to their excuses for having them. Are you beyond batches? Or still addicted?

Some hospitals are adding a step to the discharge process, a "discharge lounge." That sounds like yet another waiting room, but at the end of the process. The Cleveland Clinic has a brochure that talks about their waiting, I mean discharge, lounge. They go on to claim the process is "STREAMLINED" (their word, my shouting) by discharging ALL patients at 11 AM.

That's a huge batch process and, as the doctor from IHI would point out, that does not streamline the process. That batch process does not move the hospital and patients toward continuous flow. The IHI seminar is rightly arguing that hospitals need more continuous flow, not more batching.