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My guest for Episode #404 is Nate Hurle, a Senior Director of Enterprise Continuous Improvement at Cleveland Clinic. He was previously a guest on Episode 282. He was also recently a virtual keynote speaker for the Society for Health Systems annual conference.

Today, Nate shares stories and reflections from the past year — the pandemic year — and how Cleveland Clinic quickly stood up drive-thru testing, how they built a 1000-bed hospital (that thankfully wasn't needed), and how they've been ramping up Covid vaccination.

What happened when Nate got a surprise phone call about the need for testing to be up and running “in a few days.” Why was the approach of “get it up and running… then make it better” a useful one and how were mockups and other methods used to put safety first, given the cars and people on foot.

How did they utilize effective standardized work and training methods, huddles, and continuous improvement methods? Why was the question of “What's the most important problem to solve?” such a useful one?

How are they balancing the need for higher throughput with having a patient experience that's not too rushed? How did Cleveland Clinic get so much done in such a short period of time, and what were the lessons learned that could be applied in more normal times? Why is Cleveland Clinic now looking to continuously improve (again) their Cleveland Clinic Improvement Model?

We also chat a bit about their adoption of “Process Behavior Charts” (as I have written about) and we'll talk about that more in a future episode.

Here is the Dolly Parton video I mentioned — Please go get vaccinated when you can!

The podcast is sponsored by Stiles Associates, now in their 30th year of business. They are the go-to Lean recruiting firm serving the manufacturing, private equity and healthcare industries. Learn more.

This podcast is part of the #LeanCommunicators network. 

You can listen to the audio or watch the video, below. I hope you enjoy it like I did.

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Video of the Episode:

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Automated Transcripts (Not Defect Free)

Here is the cleaned-up, full transcript of the conversation between Mark Graban and Nate Hurle. Disfluencies and false starts have been removed for readability, and spelling corrections (including “Lisa Yerian”) have been applied.

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Lean Blog Interviews: Episode 404 with Nate Hurle

Introduction and Welcome

Mark Graban: Hi, welcome to the podcast. It's Mark Graban here, Episode 404 for March 10th, 2021. You'll learn more about him in a minute, but our guest today is Nate Hurle from the Cleveland Clinic. We're going to be talking about the past year: COVID testing, COVID vaccination, what they've done, and what they've learned there at Cleveland Clinic.

If you want to have show notes and more, you can go to leanblog.org/404. Thanks for listening. As always, please rate and review the podcast, and if this is your first time listening, please subscribe or follow us. So again, for show notes, that's leanblog.org/404. And again, I want to thank our friends at Stiles Associates for sponsoring the podcast.

We are joined today by Nate Hurle. He is a returning guest. He was here for Episode 282. Nate is the Senior Director of Enterprise Continuous Improvement at Cleveland Clinic. I hope this is still accurate–correct me if this is not correct from LinkedIn. Does that sound right, Nate?

Nate Hurle: Indeed, it is. It's still my job. Yes.

Mark Graban: Okay, well good. I should have double-checked that before we started recording.

Nate Hurle: It's good. It might have made for some awkward conversation otherwise.

Mark Graban: This is not my podcast about mistakes, but I make mistakes. Anyway, Nate was a guest on Episode 282. He was joined by one of his colleagues and partners in continuous improvement there at Cleveland Clinic, Dr. Lisa Yerian. But the stage is yours today, Nate. So welcome back.

Nate Hurle: Thanks for having me, Mark. Glad to be here.

The Virtual Conference Experience

Mark Graban: And speaking of stages, I mean, it was a virtual stage, but Nate was recently one of the keynote speakers at the Virtual Society for Health Systems Conference. We've crossed paths. Nate and I have both been at that conference together, and I'm really glad you were able to speak. How did that go?

Nate Hurle: Thanks. Yeah, as you indicated, it was virtual, so it was different. Speaking of mistakes, with any type of presentation, we recorded it ahead of time so we could avoid all the technical snafus. Then the technical snafus happened with the recording, so I had to do it live.

That was a fun experience, actually. It was great. In many ways, it was fun. It was a little bit more spontaneous. I think it was a little bit more personable, and we had some great discussion within the chat. Part of the takeaways for the virtual conferences is it really enabled the audience to have a dialogue with each other while I was sharing what we were doing at Cleveland Clinic, where they could build off each other and the questions.

As we got towards the end, naturally the questions were teed up and we were really able to have some great dialogue. So, it was kind of one-way audio, but it was two-way in terms of communication. You miss seeing people's faces and knowing really how people are reacting to what's going on–what points might be resonating with them or where their body language is indicating ¹more curiosity and perhaps² a need to explain a little bit more. So we missed on that part, but overall it was still great to be able to share what we've been up to over the last 10 years or so.

Mark Graban: Well, it's interesting if you're on a live stage in a real room and people are texting back and forth, you don't see that. I guess in a way, the chat is a form of that. You get to see what people are thinking and reacting to. It's better than nothing, I guess.

Nate Hurle: Yeah. You see the chat popping up, and naturally, you're concentrating on what you're going to talk about, but it was also good to review afterwards and see what was interesting to people.

Reflecting on the Start of the Pandemic

Mark Graban: Did you share a lot of what we're going to be talking about today, about this past year? It's been maybe almost exactly 12 months now since ramping up for the discovery and the first cases of COVID. Was that a large part of what you covered?

Nate Hurle: Actually, it wasn't. For the purposes of that conference, they had many other talks that were talking about COVID response and different projects and initiatives that people were involved in.

You're right, we're coming up on a year. I remember very visibly. It feels like I was right back in that spot when I got a phone call on March 11th at 12:25 PM saying, “Nate, what are you doing at one o'clock?” I said, “What do you need me to do?” And they said, “Will you come to this meeting? We need to have drive-through testing up by Saturday”–three days later. I said, “Sure. What's drive-through testing?” And that's how we got started almost a year ago exactly.

Mark Graban: March 11th, I believe, was the day I flew home from a healthcare client. We're coming up on a year since I've been able to be on-site with anybody. We didn't know how long that pause was going to be. I think we knew for a couple of weeks the reports and expectations were coming, but a year ago we didn't really know what was in store for us.

So, you got that call, you have this mission, there's the urgency. What happened? And I think maybe the related question to weave in is, building upon what you had already been doing–you and your colleagues–at Cleveland Clinic around lean and continuous improvement.

Nate Hurle: I think there are a couple of spots. One, the fact that there was a phone call asking for help spoke to the previous relationship that we had built across the organization. Specifically, what they were looking for were really two things. One was to help get organized around thinking about how to solve this problem. We had a new problem to solve. This particular answer to “what matters most” didn't exist a month prior. We didn't need drive-through testing. So all of a sudden it was a radical shift, but we had very good clarity around that problem that we needed to solve: drive-through testing up and running by Saturday.

They were looking for: how do we get started? And as we worked through that over the next couple of days–and we'll talk a little bit more about that–then it was: how do we make it better? Really, those two parts were what they were looking for help with. That's what our team does across the organization. We've been working towards that over the last 10 years, continuing to grow and develop in both how do we get started and then how do we make it better.

Designing the Drive-Through Process

Mark Graban: So what I hear you saying is there was the urgency to get it up and running, and we have this mindset of it wasn't going to be perfect, but it needed to be good enough. And then make it better using the methods that you've used at Cleveland Clinic. Is that fair to say?

Nate Hurle: Absolutely. So when we got started on that Wednesday, we said, “Okay, we need to be open at 11:00 AM on Saturday.” What does “open” mean? What is it that we need to really focus on? At that point, it was a pretty clear answer. First was safety.

There were two dimensions to safety at this point. One dimension was our caregiver and patient safety from COVID itself. Tremendously unknown still at this point–what to do, how to do it–but we had very good knowledge from our infection preventionists around how to prevent the spread of these kinds of diseases. It was: how do we develop and make sure we have a safe process where our caregivers aren't getting sick and also they aren't spreading it perhaps to the patient that's coming in behind for subsequent tests that may not actually have COVID? So that was the first element of safety.

The other element of safety, which was completely new to healthcare–we'd never done it before–was the fact that cars were now driving through our buildings with people in them. They didn't literally come through our buildings, but we did use a parking garage so it would be covered from the snow and the wind and the rain. That was an important early decision about how to set this up. We were looking at a surface lot, but we're in Cleveland, Ohio. Believe it or not, the weather's not perfect every day. So we decided to move inside a garage.

So we set up and made sure we had safe practices. When we opened, we had this other question that went along with it, which was: how many patients do we need to take care of? That becomes another obviously critical part of the design–understanding the demand–and that was a complete unknown. So what we decided to do was to take care of as many as we could, and our goal was always to create a process where we could handle more. But when we opened initially on Saturday morning, we were only taking care of about 30 patients an hour at that point. I say “only” because we were able to make a lot of improvements over those days.

Mark Graban: That's a fascinating challenge of trying to design a process when the demand is really unknown. That's a startup challenge as much as it is an operations challenge, or it's both.

Nate Hurle: It's very much both. When we got started with it, Mark, we really wanted to get into the design right away because we were doing two things at the same time. We were building a physical facility and we were figuring out the process. Usually, you want to figure out the process before you build a physical facility, but we didn't have time to do that. We needed to do both.

So we came up with a couple of important decisions early on. One was we were going to work really hard initially for our process to have “no roots.” We wouldn't bolt things down. It wouldn't be in a fixed position. We'd have the ability to move this around. There was a recognition that whatever we design on Saturday is probably not what we're going to be doing two days later. So we used that as a principle: no roots early on.³⁴

The other part was we really moc⁵ked up a process. We went to a conference room, grabbed a bunch of chairs, set it up, and prete⁶nded like it was a car. We got all the materials that we needed. We said, “Okay, let's pretend we need to swab someone.” We kind of figured out what to do. People would put gloves on, and then they would kind of skip steps initially, and we'd say, “No, we need to do all these steps.” We really focused–and it took us about a day and a half–working through this process over and over again to make sure that we had something that we felt was safe from a COVID perspective.⁷⁸

Initially, we then built in the safe part around the fact that we had mo⁹ving vehicles. How do we ensure that o¹⁰ur caregivers don't get hit by a moving vehicle? Really easy thing that can happen in that type of scenario. We had to come up with specific methods that we use in terms of how the cars would index forward–some things that within the lean world you'd say, “Don¹¹‘t d¹²o that because it's going to hamper production,” but we did it because we needed to maintain safety.

Mark Graban: To me, lean means safety first. And it sounds like you were putting some procedural methods in place. Not just–I wouldn't accuse you of this, but some organizations might put up signs saying, “Be careful, there are people walking.” A sign can only do so much. Can you share some examples of some of the procedural things that you put in place to really error-proof against an accident?

Nate Hurle: That is a good question because it is very much in the design. Asking people to be mindful that there's a big moving vehicle over there that could hurt you… people are going to try to do their best, but they're going to get distracted by something.

So the way that we designed it essentially was we had a very controlled lane. You can imagine a single lane; once you're in, you can't get out, and the cars are following each other. Essentially, we would have these cars index forward four at a time. There were four stations that were all doing the same thing in terms of the swabbing. The cars couldn't leave until all four were done.

You can imagine me swabbing perhaps yourself, as an example–a pretty healthy person, right? You're like, “Yep, okay, I can move my body just fine.” As opposed to a child or perhaps an elderly person where it might take a little bit longer. All four of those cars didn't necessarily finish at the same time. So we would have them wait, then we'd index them forward together and index the next four. The reason was we didn't want cars passing each other because that's when we knew we were creating the risk for vehicle accidents, and we were going to avoid that at all costs.

Handling Throughput and Demand¹³

Mark Graban: So then you had this challenge of unknown demand and then growing demand. What kind of thought went into having a process that could scale as the demand was becoming clear and as people started showing up? ¹⁴How fast was the ramp-up? How did you plan to be able to do a fast ramp-up and not be capacity constrained?

Nate Hurle: Let's start with the magnitude of the problem and then we'll talk about the design. As I mentioned, we opened that Saturday at 11:00 AM. We were taking care of about 30 cars an hour. The next day we came in–so we opened at 11:00 AM, and the reason for that is we used the morning hours to train the new people that were coming into work that day. Believe it or not, we didn't have a “COVID staff,” so we were getting people from wherever and had to train them each and every day. We used the first few hours in the morning to train them on the work.

So the next morning, I was coming in–it was probably about 6:30 or so–and there are cars lined up and there's police officers outside. Remember, we opened at 11:00. I said, “How long have the cars been here?” First car showed up at 4:00 AM. And then, “Where are these cars coming from?” Everywhere. Different states, all over the place.

Later that day, I walk out to see the cars and they're all over the city. They are backed up. The city police chief comes down to see what's going on. “Hey, can you guys speed some things up here? This is really starting to congest the city.” “Yeah, we're trying.”

It was hard for the team because there was no way we were going to be able to take care of all the demand in those early days. So how do you define success in that scenario where you can't get to the ultimate success that you really want, which is taking care of everyone? How do you feel good about the progress you're making?

We had a very simple solution to that. After you take the sample, you'd go ahead, put it in the refrigerator, and someone from the lab would come down several times a day–typically every hour or hour and a half–grab all those samples, and take them up to the lab to process them. We asked that person, “Hey, when you take the stuff out of the fridge, can you just count how many you have?” “Yeah, sure.” “Just write it on this board here. Write it right out front: what time it is, how many we did.”

This did not take long for the team to figure out what was going on. They would sit there with bated breath when he was counting and say, “How many did we do the last hour?” They were really motivated by that, but they were not motivated to work harder. That is something we spent a lot of time talking about. We aren't going to do this by working harder. We're going to do this by improving the way that we do our work. I think they were really energized by that as opposed to having to bear it on their backs. They were able to bear it on their brain.

Don't get me wrong, that was also difficult work because of the PPE they needed to wear and the fact that it was March 14th in Cleveland, which means the high was about 35 degrees. So it was difficult work for them. But we really focused and we had this measure. Then we just started asking ourselves a very simple question: “What problem do we need to solve now so that we can increase throughput?” Our objective was to increase throughput. We wanted more patients to be seen, and we asked that question over and over again. We'd identify a problem. In three days' time, we were up from 30 an hour to 115 an hour by improving the work.

Mark Graban: That wasn't adding additional lanes or additional stations. That was process improvement within that capacity?

Nate Hurle: Correct. And let's define that capacity as the people that were there to do the work. I mentioned earlier how we didn't have roots in our design, but we had four stations that were essentially doing the same thing in terms of t¹⁵he swabbing. So as we did this work over a period of time, we were able to improve that enough where initially in this station, it was a team of maybe five, if I remember right. We were able to improve it enough where now it was a team of four. So four teams of four rather than four teams of five. We just freed up enough people to create another station. So those stations were replicas of each other. By improving it, we didn't need additional labor or additional physical space. We were able to, as we do quite often, continue to redesign and shrink the space that we're in so we don't have waste of walking or transport or motion.¹⁶

Training and Mocking Up the Process¹⁷

Ma¹⁸rk Graban: A couple of things I want to go back and maybe drill into a little bit. One is to hear more about the training method. When you say there was a couple of hours, that sounds like a good investment in training. Oftentimes that gets shortchanged. We've seen instances around the world here in the vaccination stage of COVID where mistakes get made. Somebody doesn't realize that there are five or six doses in a vial. One of those cases most recently I think was Australia. The doctor said, “Yeah, I didn't do the online training.”

I kind of thought, “Oh, online training.” And then secondly, clearly, the doctor's being blamed, but I would look at this as a system problem of the design of training and confirmation that training was not just done–like check the box–but that the message was really received. Can you talk about your training method?

Nate Hurle: It was a good one. It first started with understanding what the work is, right? Writing down our standard work. So what we had was a dry-erase board that was on wheels. Again, this idea of no roots because we knew we didn't want people to have to memorize what the work is. So we positioned the dry-erase boards where they could see it while they're working with the patient. It would have these key steps as reminders: “Oh yeah, that's step one. This is step two. This is step three.” So we made it very visual. It wasn't, “Hey, we're going to train you in the morning and you have to remember all of this when you go out there two hours later and start to do it.” That was there as a reminder. We used this dry-erase board again because we knew we were going to change what the standard work was from day to day. And we did–just erase it, go ahead, write the new work up.

Once we have that standard work written on the dry-erase board, they'd come in in the morning and we would have individuals who were there to train them again from a safety perspective and a process perspective. They would demonstrate it, they would break up into small teams, and then they would practice themselves.

One of the things that we learned from that is from a quality and safety perspective, the training was going very well. People would come in, they knew what to do when we opened at 11 o'clock. But going back to how we were tracking our throughput hour by hour, we saw on the third day–this was three days in a row–that our¹⁹ productivity in the first two hours of being open was much lower than it was the rest of the day. We were like, “Well, yeah, we have new people. They're learning the job. They haven't done this job before. Every day we're having a new group of people.”

So we had a new problem to solve. How can we get this productivity up where people are comfortable with the process from being fluid with it and being in a spot where they were able to do it not only in the right content and the right sequence but also the right timing? We changed how we did the training and how we had those teams, where we would have one team leader carry over to the next day. So in these small groups of four, now one of the four of us ²⁰did this job all day yesterday and can help the others very quickly, real-time, say, “We need to change this order a little bit,” or even like, “Stand two feet that way.” Small things like that, that were either for safety or productivity reasons depending upon what the sequence of tasks were. So that was part of how we changed our training as well. It was demonstrated, it was written on a board, they got to practice it, and they had a team leader that was right there with them correcting real-time.

Mark Graban: Hearing that word “practice,” I mean, I think that's one of the keys. I've heard other organizations here in vaccination times that also used mockups as a way of testing the design and improving it before they ever went live. But then also practicing. And I think that gets shortchanged too often where training is just “Here, read this” or “Here, watch this video.” That chance to practice and come up that learning curve, and get feedback and coaching… really happy to hear you use that word practice.²¹

Nate Hurle: It's a big part. If you want people to be successful, there are not too many things I try for the first time where I'm very good at it.²²

Continuous Improvement and Huddles²³

Mark²⁴ Graban: So you have that flexibility in the training, the documentation, because you were learning a lot and there was continuous improvement. You mentioned there was this emphasis on not working harder. It's not like you were creating continuous improvement concepts that hadn't existed at Cleveland Clinic. I'm curious, what sort of methods were used? Were you doing huddles, as I've seen throughout the hospitals? Were there formal continuous improvement boards or A3s going on? What did you tap into?

Nate Hurle: That's a great question. We would have a huddle right at the beginning. So after we did the training, right before we opened, we would come together for a huddle. That was a little bit like a football huddle. What was really impactful for me around that was the emotions in that huddle. People knew why we were there. You really don't have this at work that often where you're like, “I'm ready to run through a wall. Let's go. We can do this.” It was so clear, it was so compelling. It was absolutely amazing to be a part of.

So we had that huddle, and it set the tone for the day–both in terms of effort but also in terms of thinking, and thinking about how to improve. Then we had different operational leaders throughout the process. We would come together basically every hour at that board. We would understand our performance in that last hour. The reason that we needed to understand our performance is we probably just changed something. Did it work? We needed to start there. Did it work? And did we get any better? Or, “Uh oh, that didn't quite work the way we anticipated.”

So we would start there and then we would ask the question: What is the most important problem to solve? And I'll share, Mark, that was such a critical question. I believe for the whole team, because when we were launching a process, there's lots of stuff that doesn't work well. There is a lot that if we had three months, we would have done differently. We had three days. And so there was an understanding that says we're going to launch something that isn't perfect. It's going to be functional, we'll make it better. But so everyone's bringing these problems and it can feel overwhelming. When you look at this list and you look at the line continuing to grow throughout the city, it can feel overwhelming.

We cut through that by asking what is the most important problem to solve? We had a board with a running list of those problems. We'd pick one and say, “Okay, this is what we're going to work on in the next hour.” We'd assemble a small team to go and do that. Depending upon where that problem was depended who was involved. If it was at the swabbing station, we'd work with the swabs, we'd come up with ideas, we'd bring them forward.

One example around that: when we were working with the swabs, we kind of came back to this age-old question: “What's value-added?” Why are we here? What is our purpose here? Our purpose was to swab. And everything else with that definition is waste. It might be necessary, but it's waste. So how do we start to get rid of that?

As we're standing there observing this, these four cars leave and the team is standing there waiting. They're not doing anything. They're waiting for the next four to come in. We say, “Wow, while we're standing there, we're not doing anything. How can we have those next four kind of right behind?” As soon as these four leave, boom, there's the next four. We have a police officer down there and he says, “I'm trained to move vehicles. I'm trained to control traffic. How about I stand there? I'll watch when these four move and I'll get these four moving right behind. I'll come to the end and I'll tell them exactly where to stop and then I'll go back and I'll do it again.” “Oh, that's a fantastic idea.” So we did that. That saved maybe 10 or 15 seconds, which might not sound like a lot, but when you have a three-minute process, it's huge.

Mark Graban: Right. Adds up.

Nate Hurle: And so that was an improvement that the team came up with. It was a cross-functional team. Those types of examples were happening a ton over those three days.

Escalation of Issues and Tiered Huddles

Mark Graban: Were there any instances where–I know that we've talked before about the tiered huddles at Cleveland Clinic–was there any semblance of that where things that couldn't be addressed right within the team would get escalated?²⁵

Nate Hurle: Yeah. There were a couple of different places. When you think about the extended ²⁶value stream, you have this collection process because that's really what we are in the middle of: a sample collection. But downstream from that, you actually have running the samples. Upstream from that, you have all the supplies that need to come in. And upstream from that, you have all the ordering that needs to be done by the physicians to enable people to have these tests.

So what happened early on… again, so much of this was unknown. So when we opened that Thursday, we said any physician can place an order for a COVID test. Well, you can imagine probably what happened–lots. And that was something that got raised up that said, “Whoa, we got way more orders here than we can ever handle, unfortunately.” We don't want to be in that spot, but that was the reality. So we are going to have to reduce this in some way. That was a different problem for a different group to solve. They ended up making decisions about prioritization based upon symptoms or risks, comorbidities, and such.

Other groups handled supply chain-related issues. Maybe we were running low on the swabs themselves, and so that was a way that we were able to get more broadly connected to other parts of the supply chain. This wasn't as directly tied into our daily tiered huddles because we were more like hourly tiered huddles, right? Where it was just moving super fast. But the biggest issues would be raised at those levels and we'd make sure our leaders were aware of the following day: “Hey, here's an issue. Here's what we did about it. Here's what our next steps are.”

And in turn, other priorities would come back to us. I think it was the second or third day, one of the priorities that came back to us is: “We need a way to test our own caregivers. How are we going to test them so that we can get them back to work?” Because we also had this issue of we don't want a potential caregiver who might have COVID working inside our hospital. So we needed to figure that out relatively fast. We had to develop a slightly different process that integrated into this overall one to be able to take care of our own.

Balancing Efficiency and Patient Experience

Mark Graban: You talked about this question around “what's the most important problem to solve” and trying to prioritize. You mentioned the throughput challenge. I was talking to some people yesterday–this is now looking ahead to the vaccination phase where, like you were saying, in your case, the value add was swabbing and here it's needle in the arm. But they were talking about the need to speed that up, especially when vaccine supply won't be so much the constraint, but then looking at balancing the patient experience.

If at some point could it be too fast? I think of a good lean assembly line where the employee can stop the line, pull the andon cord. The scenario people were talking about yesterday is almost the patient reaching up and pulling the andon cord and saying, “Well, wait a minute, I've got questions. That was really efficient, but I haven't been anywhere near a medical professional in a while.” They were trying to think through how to account for that variation.

So my question for you is: what sort of thought process or experience went around balancing out throughput and efficiency with what some of the patients' needs might be? I know obviously, “Patients First” being the philosophy there at Cleveland Clinic.

Nate Hurle: That's a great question because there are always issues that start to come up that are going to take a little bit longer. And so you work to address those that you can within that moment. And then at some point there's this recognition that says, “Hey, this is going to take us a little longer to resolve this particular issue.”

What we ended up doing within that drive-through is we did end up creating a spot where essentially a car could pull off into what we called a rest area, so we could have that longer conversation and move that work kind of outside and allow the rest of the line to continue. That was an accommodation that we made that addressed two different things.

One: patient has lots of questions. Maybe sometimes we would also, in those early days, most cars only had one patient that needed to be swabbed, but some would roll through with five. You can imagine what that does to the overall process. Initially, it just slowed everything down. But then we figured out how to solve that problem and that's when we created that rest area. “Hey, that five? No problem. You go over to this rest area, we'll take care of you there.” And the rest of the process continued. We would also be able to use that to address any longer patient conversations or questions because naturally there were a lot. Everything was unknown at that point in time.

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Mark Graban: What you're describing, that pull-off, it reminds me of what a Chick-fil-A might do if there is a delay or a problem or some special order that interrupts the flow. I think of Chick-fil-A because there was a case here with vaccination–I think it was around Atlanta–of a Chick-fil-A store manager coming in and helping direct and fix some of the flow for a drive-through vaccination service. He was building on his operations experience of a really busy drive-through line.

Nate Hurle: Yeah. There's a lot of similarities there. This gets back into another improvement. At first, we said first come, first served when we opened on Saturday, which was why someone was there at four in the morning for us opening at 11. And then we shifted. This one took a little bit longer–I want to say it was maybe about a week. We shifted to appointments.

That was a whole problem that we had to solve because we don't schedule typically lab appointments. If you go in for a blood draw, you just walk in. So we didn't have a system set up that was equivalent for this type of process. We had a new problem that we had to solve where we wanted to spread out the demand a little bit. And that led to better patient experience too. I didn't have to wait in line for 10 hours. I could go down at my assigned time and get through there. Now people tell me they get through in about 15 minutes, so it's a lot better.

The 1,000-Bed Hospital Project

Mark Graban: One other thing a lot of organizations around the country had to do was set up additional hospital bed capacity–convention centers and arenas and other settings, or Navy boats being docked–because there was so much unknown about how many ICU beds would be needed. You went through a similar process. I was wondering if you could talk a little bit shifting now from that early testing phase to the unknowns and the planning and the design around additional beds.

Nate Hurle: It was probably about two to three weeks after we got the testing up and running. Our next problem to solve is, as you were getting at, we were concerned about how many patients we would end up having to care for–that we weren't prepared. We had a lot of surge plans that were inside our hospital–let's use this space and let's use this space–but as you were describing, people knew we were going to run out of room.

So what we did is we have an academic medical building that is relatively new, right on our campus. It's a very large building, and we said we are going to convert this building into a 1,000-bed hospital with each of those beds having oxygen. That's the big difference between what you see in a lot of the images on TV. Most of those are cots without oxygen. We were going to have oxygen available for every one of these patients because they're in the hospital; if they have COVID, they probably have some oxygen issues. We were recognizing that and said, “Look, if they're okay to be on a cot and not on oxygen, it's probably time for them to go home.”

We started working towards that and that was a big challenge in many different ways. We had kind of your engineering type of challenge of how do you plumb oxygen into a building that isn't retrofitted to do that. But we also had tremendous other types of flow issues, and those flow issues were back to safety for our caregivers.

When you think about a 1,000-bed hospital and the assumed scenario here is that the whole hospital is COVID positive… so if you are out in this hospital, it is assumed to be COVID positive, and so you have to be protected from a PPE perspective. How do you bring people in just at the start of shift? How do you bring people in so that they can put on their PPE and go out and take care of patients? That is a huge logistical challenge. How do you handle breaks and lunches and bathrooms for all the people that need to work there, as well as all of the patients that are in this space? How do you handle the resupply process? If this is all COVID positive, how do I actually get the material here in a safe way and then go back to the rest of my job? How do we run samples back and forth between this building and our lab?

So we had all these flows that we had to figure out, and we had three weeks to do it. Three weeks to build a 1,000-bed hospital. Thankfully the building was already built, so we didn't have to wait for that lead time, but we did have to retrofit a lot.

Similar to our drive-through experience, we did lots of simulation. So we would identify all these problems, and we had this huge whiteboard that was probably about 40 feet long in this room. We'd make a list of all the problems and all the issues we need to figure out. And then we would say, “Okay, which one do we need to work on now?” We knew we needed to figure out a couple of things early on because the engineering and construction team needed some answers. They needed some answers that say, “Okay, if I'm building a space for people to put on thei²⁷r PPE, how big does it need to be? What do you need in this space? Because I got work I gotta go do, but I need you to tell me the design criteria around this.”

So we would figure those out together and we would do lots of walkthroughs and mockups. And then they'd launch an engineering and construction team and poof, a couple of days later there it was. It was absolutely amazing. We're fortunate we never had to see a single patient in that hospital. So I look at that also and say we have the only hospital that never had any quality or safety issues. I was kind of proud of that. But that's probably because no patients came in, thankfully.

Mark Graban: Those construction crews probably had the same mindset you were describing earlier of having the sense of purpose and urgency. “I'm going to run through walls.” Maybe there were times they did have to run through walls with the piping. But I'm sure that motivation again was really powerful.

Nate Hurle: People asked, “How come we can't do this–like, get all this done as quickly as we did at the beginning of COVID–in our normal work?” They ask that question a lot. As we're doing some reflection on why that is the case, I think it first starts with incredible clarity of purpose. Real clarity of purpose. “Drive-through testing open, run by Saturday at 11:00 AM.” That was the charge to the team. And the team was then charged with: “Go figure out how to do this.” They didn't have all this other stuff that they needed to consider. But it was great, clear purpose, and the team could work towards that.

The second was obviously an incredible focus on that in terms of the energy and the resources and the intensity. I used to be back before I joined Cleveland Clinic, I worked for Kodak and we did a lot of rapid improvement events there. I learned to talk through those and those were very useful and we made many improvements. And they were very tiring. They were very tiring because of the level of intensity. People were able to do this during the time of COVID. We were all digging much deeper than we had before. We were fueled by that. But you can't necessarily work in that level of intensity for 15 years.

Mark Graban: At what point does fatigue or burnout kick in? Is that a sustainable pace?

Nate Hurle: That pace is probably not sustainable, but the idea that says, “Hey, we're going to carve people out to focus on this problem and provide great clarity around what this problem is that we're trying to solve”–I do think those are two things that we can take away from the last year.

Mark Graban: And I'm sure that purpose included the clarity around what needed to be done by when, but the why was really powerful. This was not an arbitrary “let's just do it in rush just so someone could check a box in some plan.” I mean, there was real community need, medical need, organizational need.

Nate Hurle: There was probably the most powerful why. It was when you knew you were there for everybody else. You were there for your family, you were there for your friends, you were there for people you didn't know. But everybody was in it for the same reason. So the why was incredibly strong.

Shift to Virtual Care

Mark Graban: I've heard a number of cases at different health systems where as clinics started to open back up, the need for telemedicine was now very clear and urgent. It was no longer a nice-to-have thing on a roadmap. I've heard a number of executives say that “Our five-year plan turned into a three-week implementation,” which is an interesting lesson around nice-to-have versus must-have, optional versus required.²⁸

Nate Hurle: We had the same situation in our organization. Visits went w²⁹ay down–in-person visits went way down–and virtual visits went way up. It's something we've had on our plan and has been part of our interest for many years. We have been doing it, but the amount just went absolutely through the roof.³⁰³¹

I think it's another example of once we have some good clarity… one, ³²there ³³also becomes a little bit more acceptance of something not working exactly right. So we had some technology issues. You're trying to ramp up this and just like we all had at home with Zoom or Teams or whatever–internet speed, so on and so forth. We had some of those early on and we've made improv³⁴ements over the last year in the technology to make it more robust, repeatable, reliable for both our providers who are on one end as well as our patients who are on the other end of that visit.

But it was early on like, “Okay, we know it doesn't work exactly right, but I really want to see you to talk about your diabetes or whatever issue is really important. And we don't want to let that go. We need to have this dialogue and this conversation.” So we've seen tremendous changes over the last year. Our goal this year, we're looking for about 20% of our outpatient visits to be virtual. So we want to maintain that. We think it's great for the patients. I know when I'm a patient, I absolutely love it. I do way more virtual than I do in-person now, and I think I'll stay that way forever. It just saves time in the car and all that other stuff.

Mark Graban: I mean that compelling value proposition was the reason why it was on roadmaps and why it was planned, and that day is now here. One data point: the one and only virtual visit I've done, maybe a month ago, I was told, “Log into the video visit 15 minutes early.” And to be honest, I kind of rolled my eyes and said, “Great, I'm going to log in and how long am I going to sit there?” I mean, I could multitask, kind of like if I was in a waiting room, but all right, w³⁵ell, they want me to log i³⁶n 15 minutes early. I'm a rule follower. I logged in 15 minutes early and I was pleasantly surprised. The provider got into the video visit 10 minutes before the scheduled time, and we were done. It was a very quick follow-up kind of thing. And it was all done before the scheduled time arrived. So I thought, well, great. I didn't just replace waiting in an exam room with waiting at home. I don't know if I was lucky, but anyway, I was really happy with that outcome.

Nate Hurle: It's been great for me. I mean, over the last couple of years, because I did the video visits even before the pandemic. I've used it in many different situations. It saved my family a trip to the emergency department after my son's bicycle accident. You know, get someone to give you an opinion: “Hey, do I need to go to the emergency room? Here's where we're at.” As a parent in that scenario, you want to make sure your child's safe, of course. So it was affirming to hear a medical professional give us the direction of what we needed to do. I think we're here to stay, and the inventions by every organization were absolutely tremendous. Video visits were one of those.

The Vaccination Process

Mark Graban: So we've covered the testing phase and planned ramp-up and starting to get back to care and the different changes that have taken place. So maybe the last thing we can touch on is vaccination. A new ramp-up. A different process. I was wondering, Nate, if you can share a little bit of the story there and the process and what you've learned and what you are continuing to learn.

Nate Hurle: We've had a great team work on the vaccination process. I was very personally involved in those first two examples. Not as involved in the vaccination personally, but our team has been–Holly Born from our team has been doing a tremendous job in that space along with our pharmacists and our nurse and again, our construction people, so on and so forth.

They followed a lot of what we created early on and you were describing that, Mark, in terms of let's develop what we think could work, let's practice it, let's mock it up, and let's make sure we have clear, robust process in order to be able to handle this.

I've been fortunate, I've been able to go through and get my vaccination. As I'm sure we do in any process, we tend to enter, we kind of watch it with a certain eye. “Hey, let's take a little closer look at this.” My observation in the vaccination process is one, it is an efficient process in that you come in, you check in, you say who you are, and then you go in. In our case, we have small little tents set up for privacy. It's inside a ballroom in a hotel that is attached to our campus³⁷.

After you have your vaccination, “Any questions? Nope.” And I thought this was the best part. So when we go around, we want to make sure that patients don't have an allergic reaction. Now you have a lot of people to keep track of. How do you make sure that they actually stay for that 15 minutes and make sure they're okay? They just give timers. They press start, it counts down 15 minutes. They go have a seat in any of these seats. Timer goes off, you bring it back up, they clean it, it's ready for the next person.

Mark Graban: Like one of these little just kind of digital timers. It's like the size of a business card?

Nate Hurle: Exactly. And I thought that was a fantastic way because, you have so many people coming through, how does any individual keep track of 15 minutes? I thought that was just an ingenious approach to put it in the hands of others, literally with a timer. “When this goes off, you're free to leave.” And that has worked really well.

We've been in the middle of vaccination within the state of Ohio. And that's, again, I would say there's some similarities to what we were describing in the drive-through testing. You have the whole process of what the patient sees in terms of the actual vaccination administration, but then you have the whole supply chain. The supplies beforehand: keeping it really cold, making sure that you take it out so you don't waste it. So again, figuring out all of those details of: Where are we going to put these special freezers? How are we going to get it from point A to the point of actual administration? How are we going to make sure that it has the appropriate time to thaw? And obviously, most importantly, how are we going to make sure that we don't waste these precious resources?

Again, very common items to what we're used to when we think about process. We don't want waste, we don't want scrap that's thrown away. If we're making aluminum cans, we don't want to waste the aluminum. In this case, it's even more precious in terms of what that vaccination represents to people. And so we created processes to make sure that we didn't have waste. And that was having a standby list. Very early on, we created the standby list where we could call people and say, “Hey, we had five no-shows today. Would you like to come down? You're next on the standby list.”

Mark Graban: Going back to two little details I'm curious about. When you talk about the privacy, I've seen a lot of videos and pictures of different setups. Is the privacy a matter of, I guess if you're in a warm weather climate, people might have short-sleeve shirts? Being Cleveland, if it's cold and people have sweaters, getting access to the arm may require a state of undress that people would want privacy for.³⁸

Nate Hurle: That was certai³⁹nly a big driver in it. Recognizing that when we started to administer, it was still pretty cold outside, so people were coming in with their coats and their sweaters. So that certainly enables it.⁴⁰⁴¹

And I think it's part of our patient experience element as well. You were describing that earlier–how do you keep patients first? So I ⁴²think it creates a tighter connection between the nurse or whome⁴³ver is administering the vaccine and the patient themselves. It creates a space for dialogue, for questions, a little bit more calm in that particular moment. There's obviously, as we know, a degree of nervousness for a lot of people. A lot of people are excited about it and a lot of people are nervous about it. So it gave them a space to be able to ask questions that was kind of a little bit insulated from the rest of the public.

Mark Graban: Thinking of clothing… you might not have seen, but Dolly Parton put out a video of her vaccination at Vanderbilt. It's cute. She's very funny, but she's sending an important message of encouraging people to get vaccinated. She wore a top, and I forget what my wife called it–but the blouse had cutouts in the shoulder and enough down into her arm that gave a perfect window. I know that was an intentional choice on her part. Perfect window for the vaccinator to come in with the needle.

Nate Hurle: Yeah. It's kind of taking the setup steps and going from internal to external Single Minute Exchange of Die (SMED) principles. Dolly Parton was all over it, it sounds like.

Mark Graban: Yeah, and I talked to somebody else yesterday when you were talking about that external setup. They had set up basically for each lane of people being vaccinated, two teams, and basically it's just kind of flipping in, flipping out, doing the setup and then coming in to work with the patient. And then team two is prepping and just having this constant cycling through to minimize the time.⁴⁴

And in that video with Dolly, she actually⁴⁵ gets a little impatient. She's being cute about it, but she's getting a little impatient and fussy with the doctor because he is fiddling with, I think, opening the syringe package and the stuff that you and I would look at and say, “Oh, that should have been externalized. Don't make Dolly, don't make any patient wait. You could do that in advance.” So it's really interesting to see how people are innovating and doing things to help improve flow.

Nate Hurle: So we did that within the drive-through. We chose not to do it within the vaccination. And I think there's a design difference. Within the drive-through, space was very constrained and people changing PPE was even longer between patients. And so we would have this team that would come in, they'd swab, they would come out and they'd work, change their PPE, wash their hands, don their new PPE and come back. So we essentially were able to do that to keep that flow of cars going because we were constrained in a physical space.

Where we are doing our vaccinations currently, we're not as constrained in the physical space. So we've just kind of spread out the stations rather than them having swapping at the spot. I think part of what you're getting there is you need to understand what problem you're trying to solve. And perhaps if you're in one of these large mega sites, maybe that is the way you want to do it, and maybe if you're in a smaller site, you don't need to do that. So understanding what problem you're trying to solve is really important before we go ahead and put in a particular practice.

Mark Graban: Yeah, and that's a great reminder of taking a look at your own work and your own circumstances instead of just copying a “best practice.”

The Cleveland Clinic Improvement Model

Mark Graban: So there are a lot of longstanding good practices at Cleveland Clinic. It was a chance to recap, and again, I would encourage people, if you want some of the background, you can go back to Episode 282 and listen to Nate and Dr. Lisa Yerian talk a little bit more about the background of continuous improvement at Cleveland Clinic.

But I think one thing that is noteworthy and worth looking at–to learn from, not to copy–is the Cleveland Clinic Improvement Model. I was wondering if you could just give maybe the elevator pitch about that. I'll link to it in the show notes where people can find this online. What is that model and why has that been useful?

Nate Hurle: Thanks for asking that question, Mark. This model really serves as our aspiration. It is what we want to become across Cleveland Clinic in terms of the way that we improve. It's a unifying model: quality improvements, patient experience improvements, productivity improvements, so on and so forth.

Really what we do within the model is we outline the behaviors that we're looking for–the behaviors of senior leaders, managers, and those that are doing the work each and every day. Because we all have different responsibilities and it's how those connect that really drive our ability to improve.

Additionally, we've outlined in our organization what we feel is important, our four key systems: Organizational Alignment, Visual Management, Problem Solving, Standardization. We feel those are important for us. For a different organization, it might be a different set of systems, it might be a different set of behaviors. We use this as our aspiration and our roadmap and say, “This is what we want to create,” and then we create the systems to support the behavior.

So you mentioned tiered huddles as an earlier example. That is a system that we created to help our organization identify and solve problems each and every day. We do it throughout our organization every day, where we are looking to understand what problems are getting in the way of providing care and solving and resolving those problems, as well as understanding our daily operations. So we create these systems that support the behaviors.

Just before I came on with you, we were actually looking at the improvement model because every year we revise it, we improve it. We realize that our organization continues to evolve and change. So I was with a cross-functional team, people from other parts of the organization outside of our continuo⁴⁶us improvement team, getting their input on potential changes to the improvement model. As you like to say, we “improve the way we improve” and that is something that we take really seriously.

I was just starting to look through the past years and say, maybe there's a story here. If I go all the way back to the first one in 2014-15 and look at each year, what's the story of how it's changed and evolved over time? Part of that story is it has evolved as Cleveland Clinic has evolved. Our focus on patients, empathy, our focus on high reliability, our focus on speaking up–all of those things are becoming stronger and stronger parts of our improvement.

Mark Graban: There are certain principles that are very consistent, like “Patients First” I imagine is forever a foundation at Cleveland Clinic, but then some of the details and the specifics within the frameworks of ⁴⁷values and principles then evolve. Very true. So I hope everyone will go check that. I'll make sure I'm linking to the latest revision.⁴⁸

Process Behav⁴⁹ior Charts

Mark Graban: Maybe just one last question, and maybe we leave this as a teaser for a future episode. Perhaps like when things calm down a little bit. You've had the opportunity to use Process Behavior Charts, a topic near and dear to my heart. It's a method that I've shared in my book Measures of Success. I was wondering again, maybe just on an elevator pitch scale, if you could share just a little bit and we can dive into that deeper.

Nate Hurle: I'd love to have that conversation because I think it's fundamental to these problems that we try to solve as continuous improvement professionals and as an organization. And that is back to this question of first: What matters most? Which problems am I trying to improve? And secondarily: Is this getting better, worse, or staying the same? Because that helps reinforce what problems I need to solve.

So we've started to use them with the majority of our measures so that we can look at our performance over time and we can say things like, “Hey, this is essentially the same. It's not getting better, it's not getting worse.” And maybe for this particular measure, that's okay. For this measure, “staying the same” might not be okay, and we need to do something different and we need to engage in problem-solving.

So we use those. We've built a series of dashboards with our colleagues in Business Intelligence. They've done just an absolutely fantastic job of making it very easy for the user to take advantage of this knowledge. And what I mean by that is you don't need to be a Six Sigma Black Belt to take advantage of what these tools can do for you. You don't need to have a degree in statistics or engineering to take advantage of these tools. We present it in a way to the user where the limits are automatically calculated and whether or not it is stable or unstable is also automatically calculated. In turn, what that allows people to do is say, “Ah, this is unstable. I need to go understand why.” And that's how we're using it across our organization. We've made tremendous progress over the last couple of years. We had you visit us a few years ago and share the thinking in your book with the team, and it has been absolutely fantastic and allowed us to talk about the things that are most important⁵⁰.⁵¹

Mark Graban: Well, that's great, and I like the way you're i⁵²ntegrating that and incorporating that. So I'll look forward to hearing more. For those who are listening and not watching on YouTube, when Nate was saying “staying the same,” you couldn't see his finger kind of suggesting the fluctuation up and down, let's say around an average. So the quote-unquote “the same”–it's not really the same, but…⁵³

Nate Hurle: Great point. Yeah, I gotta work on my radio skills.⁵⁴⁵⁵⁵⁶

Closing⁵⁷⁵⁸

Mark Graban: That's okay. And for those of you who are just listening, you don't see that Nate is enjoying a bright sunny day in Cleveland, Ohio. So, Nate, thank you for not b⁵⁹eing outside in the sun and enjoying that. Thank you for being he⁶⁰re on the podcast with us, and thank you for sharing the important work that's being done and continues to be done at Cleveland Clinic. I really appreciate you being able to share that with us.

Nate Hurle: Thanks, Mark. You know what? I'm here on behalf of just an amazing team. I've been at the Clinic now for 14 years, and the reason is the people are absolutely incredible. People on our continuous improvement team are partners in the organization, in nursing and quality, our providers. We just have an absolute world-class team and we're blessed to be a part of it, so thanks for letting us share our story.

Mark Graban: Of course. Thanks.

Announcer: Bye-bye. 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 at leanpodcast@gmail.com.

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