Lean Methods to Improve Cardiac Surgery Featured in Annals of Thoracic Surgery
Hat tip to my friend and fellow Productivity Press author Naida Grunden for pointing out an article she is a co-author on, “Improving Patient Care in Cardiac Surgery Using Toyota Production System Based Methodology,” published in the journal of The Society of Thoracic Surgeons. I'm sorry that I can't share the full article, due to copyright restrictions, but I'll give highlights here.
From the summary of the article, freely available online:
Conclusions: By the systematic use of a real time, highly formatted problem-solving methodology, processes of care improved daily. Using carefully disciplined teamwork, reliable implementation of evidence-based protocols was realized by empowering the front line to make improvements. Low rates of complications were observed, and a cost savings of $3,497 per each case of isolated coronary artery bypass graft was realized.
It's great to see more peer-reviewed evidence that Lean and TPS methods can be used to both improve quality and reduce the cost of care.
The introduction to the article cites Dr. W. Edwards Deming and his philosophical contributions to Lean, stating that “reducing defects from complex processes results in less variable outcomes and higher quality.”
The article features the Ed Dardanell Heart and Vascular Center (HVC) that's part of Forbes Regional Hospital in Monroeville, PA. Given their proximity, they received assistance foam the Kennametal Center for Operational Excellence (KCOE) at St. Vincent College, including Dr. Richard Kunkel, who aI had the pleasure to meet when I spoke at their annual conference.
Lean for HVC included the vision statement of “perfect care” and their defined value stream (from initial contact with the HVC to the patient's full recovery) would be improved through methods of “daily safe improvement, originating from the frontline of work.”
Lean mindsets used in this work included:
- Focusing on the value stream
- Balanced scorecard of safety, quality, productivity, human development, cost
- Performance measures reviewed by the team daily
- Daily team huddles
- Structured problem solving sheets (used 923 times)
- Proper problem definition (not jumping to solutions)
- Root cause analysis
- Fast resolution of safety issues (24 hours) and other problems (48 hours)
The daily problem solving as described as a “systematic approach, by helping the nurses to fix defects as they occur, produces ownership of work and caregiver pride.” This method included a “no blame” mindset as part of a culture where “problems are blessings” instead of a setting where “problems are punished.”
Having the nurses involved in daily improvement has “greatly improved glycemic control” for patients.
Other tools were introduced, but only in response to particular problems and needs, such as:
- visual management
- single-piece flow
As the article states, “the tools were learned and applied in the context of work, as needed, and not in the classroom.” This is a great approach for learning-by-doing.
So what were the results from this 24-month effort, compared to a “Like Group” from the same period? Results included:
- Reduction of Length of Stay by 1 day (from 9.1 days to 7.9)
- Reduction of post-operative LOS by 1 day (from 6.8 days to 5.8)
- Shorter ICU stay (from 72 hours to 35.1)
- Shorter ventilation time (from 22 hours to 11.2)
- Less operative mortality (from 2.1% to 0.4%)
- Fewer complications (From 37.5% to 16.1%)
- ZERO infections (compared to 1.5% in the Like Group)
On the negative side, 30-day readmission rates were slightly higher (12.6% compared to 10.6% in the Like Group).
Patient satisfaction is rated at 99%, per the article.
In the article's commentary, they cite nearby Geisinger Medical Center and their 40-step CABG surgery bundle (as famously featured in the New York Times piece ” “, which I blogged about here. The authors of this article question whether Geisinger had just a one-time standardization effort, without continuous improvement, as they write:
“… it is not evident in these notable efforts how cultural change occurs so all caregivers and administrators are continually learning to perform rapid-cycle safe improvement.”
The article concludes by claiming that:
“The effect of OE has been remarkable. Methodically, problems are addressed daily as they arise, and the risk-adjusted incidence of major adverse events has decreased by 50%… cost savings of $884,900 in the isolated CABG cohort have resulted… emphasis on safety and quality saves large amounts of money by reducing defects in care.”
Congratulations to everybody involved and best wishes for their continued improvement efforts.
You can find Naida's outstanding book (The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods) via Amazon and other booksellers. In the coming weeks, I'll have two podcasts with Naida, as well, so please come back for those at www.leanpodcast.org or in the iTunes feed (also in RSS).