LEAN HEALTHCARE, EXAMPLES FROM THE U.S.
FINAL VERSION
By: Gunn Iren Kleppe
Seattle Children’s Journey – One of the First Seattle Children’s Hospital was one of the first medical centers to apply Toyota’s Production System (TPS) to healthcare in the U.S. Their own program, Continuous Performance Improvement (CPI), examines all aspects of the patient’s journey through the hospital, looking for improvements that ultimately benefit the patient and their family. “We think of it as a system of getting better all the time,” says Cara Bailey, Vice President of Continuous Performance Improvement. Bailey feels the program has unified their approach to improvement. “We now have a common language for leaders to talk about improvement. You get a lot of synergy from that,” she explains. The decision was made not to include the term Lean in the program’s name, as they felt it did not sufficiently capture what they were trying to achieve. “Toyota does not refer to their philosophy as Lean, and we thought some of the negative connotations of the term would be a barrier to staff engagement. But we have made a conscious effort to stay true to the philosophy of TPS.” Cost improvement a side effect Seattle Children’s has applied CPI principles to improve their performance in all five dimensions: quality, safety, delivery, cost, and engagement (staff). “We really believe that if you look at improvement from all angles, you will improve your cost,” says Bailey. When they began this work in the late 1990s, Seattle Children’s was fortunate in not having to come to this from a financial crisis. “Each organization needs to approach this work from whatever their burning platform is.” Coming at this from a pure cost efficiency angle, however, could make it very difficult to get staff onboard, in Bailey’s opinion. Employees might suspect this is just another trick to make them work harder. That, to Bailey, is a natural conclusion. “If you aren’t hearing some resistance from your people as you begin this work, then you aren’t really listening. We welcome the healthy skeptics. That’s especially key to engaging medical staff,” she argues. Engaging staff without giving them some experience with improvements early, however, is difficult. That was the reason for implementing many early rapid improvement events. This allowed staff to see for themselves that something that had been bothering them for years could be improved quickly. Participating convinces staff that CPI philosophy and tools really can improve their work. Not another flavor of the month “We have now been involved in this long enough that people understand it is not the ‘flavor of the month.’ It helps them do their jobs better; it is not about taking things away,” Bailey assures. “We take waste out of the process. We don’t want to burden our people with wasteful processes.” A commitment was made from the start that no staff would be laid off as a result of the improvement efforts. “Nothing stops your improvement efforts faster than if staff is
wondering if their job will go away,” she emphasizes. If nurses’ time is freed up, they are able to spend more time at the bedside. “I believe that is where the true value is added.” Commitment from the Board of Trustees has been a key to success. Early in their CPI efforts, the Board approved the financial commitment necessary to build the CPI infrastructure—the CPI office and development resources to provide learning opportunities for all staff. The Board also applied the CPI philosophy and tools to their own process improvement initiative, in order to experience the power of CPI first-hand. When the long-tenured CEO retired a few years later, the Board’s commitment to CPI was demonstrated in their recruitment of a new leader who was also willing to support the continued development of CPI as the organizational philosophy. Buy-in necessary “Leadership involvement is key,” Bailey continues. The hospital made a conscious effort to bring the right leaders, including physicians, on board early in the process. They also partnered with a local manufacturer that was implementing Lean, to be one of their key learning sites. Taking people out of their comfort zone helps them focus on flow and other Lean concepts. “We found out it is often not as helpful to take them to a hospital because we tend to focus on the clinical content of the work, not how the work is flowing,” she explains. “The biggest shift is really in the minds of the leaders. We have learned over time that our traditional ways of managing don’t work in a true CPI environment,” Bailey explains. Leaders with a more authoritative approach may find it challenging to engage people on the front line. “Traditionally we get very impatient to get to an outcome without fully understanding the current state and designing our interventions as experiments, so this approach takes a whole new kind of leadership skill.” Implementation Seattle Children’s started in the late 90s with improvement events in non-clinical areas. This allowed them to safely experiment and prove the concept to themselves before moving closer to the patient. They then expanded into some clinical support areas such as lab and pharmacy. These are all fairly linear processes where it is easy to see the flow—or lack thereof. Over time, efforts were introduced into direct patient care, involving physician leaders. Patient safety was a big driver. “Our customer is always the patient and their family, regardless of what process we’re working on,” Bailey asserts. After having started with point improvements, they started looking at horizontal perspectives, such as the journey of a cancer patient through the health care system. A few years later they began applying the concepts to the design of new buildings. “Facility design is a whole new area, which has proven to be successful,” says Bailey. By building an ambulatory surgical center using Lean principles, great improvements were made in patient flow. They were able to build smaller, save money, decrease lead time, and reduce the number of change orders for the building project. They have since employed Lean principles in planning yet another facility, which is opening in April 2013.
Long term commitment is key “We have had improvements in just about every area,” states Bailey. “It doesn’t mean we don’t have a lot of room for improvement. We still have a long way to go.” These days, Bailey spends most of her time with management systems and strategy deployment. “If I could do it over, I would implement a more robust daily management system early on. It is what really enables you to sustain the improvements. It is good that we figured it out, but we should have started it 5-6 years ago.” Bailey cautions against seeing Lean as an opportunity to cut costs short term or giving up due to impatience. “Long term commitment is key,” she stresses. “We say this effort is generational. It won’t be done in our lifetime. If you are looking for a quick fix—this isn’t it. You can get great early wins, but it is not sustainable if it isn’t a continuous effort.” “Absolutely, healthcare needs this,” she concludes. The Medical Perspective Dr. Howard Jeffries has been Medical Director of CPI at Seattle Children’s Hospital since 2008, the first person in that role. Previously, Dr. Jeffries was Director of Quality for the Intensive Care Unit (ICU). In his current role, Dr. Jeffries leads the work around clinical standards, which has to do with implementing and improving diagnosis based pathways to ensure the best possible standard of care. “It was a culture change we wanted to bring in,” he explains. “It has been a transformation in how physicians think about continued performance improvement.” After starting with point improvements during 1999-2001 in non-clinical areas, they eventually worked their way closer to the patient. The goal is for everything to be patient driven. Standardizing work One of Dr. Jeffries’ first projects involved improving physician to physician communication during physician hand-ons (transferring patients from ICU to the floor). In fact, standardization efforts have included all medical staff in order to improve communication. Standards have been developed and put in place over a five-year period. They have also standardized how rounds are conducted. Another example is how community physicians admit patients directly. This was a big pain point, which used to require about 60 steps and 30 phone calls. Thus far, the number of steps has been reduced to 17 and phone calls to about 8. “The goal is one call, one step. We are not there yet,” admits Jeffries. Yet another initiative involves making care independent of who the patient sees. By standardizing care, anything that does not respond to standardized treatment, alerts one to the exceptions. When a patient doesn’t follow expected outcomes of standard care, that is a critical
clue to figure out why and learn from the deviation. “You have to have a standard to be able to ask ‘Why,’ otherwise it becomes random,” argues Jeffries. In 2005, the hospital started applying Lean principles to blood stream infections. The initiative succeeded in reducing the number of infections. By spreading the practices across the hospital, infections were in turn reduced hospital-wide. Everybody can do better “You can always make something better,” Jeffries points out. Even though you don’t reach perfection, to make something 5 % better, is better than zero. No matter what the area, the goal should be to make what you do, easier. It should make care safer. “How do we use what we learn about waste, quality, and mistake-proofing and bring that to bear on clinic decision-making and tools?” To Jeffries, that is a key question. When you embark upon this kind of effort, people might ask, ‘Why are you changing my life?’ “We then ask, ‘Can you say right now what you do is the best?’” challenges Jeffries. “Everybody could do better. Healthcare has to get better. You have to try something to improve and you have to become fully immersed in it. We started gingerly with CPI, as there wasn’t evidence then. However, now there’s good evidence from a variety of hospitals that this works on health care,” he points out. Has to become part of your DNA To be successful, you need to get leaders onboard and get them engaged. “The only way for this to work is to have that engagement,” confirms Jeffries, who recommends taking small steps and making steady progress. “Whatever improvements you make, put a system around it. It has to be part of your culture, be part of your DNA. There are other methodologies, but we really feel, we believe that this is a great method.” In Jeffries’ experience, some leaders have kept up with it, others have not. Therefore, it is important to have that daily management system in place. Seattle Children’s continues to track, audit and follow up on their efforts. “We have an organization that embraced the ability to change,” says Jeffries. “We realize this work is generational, it takes a long time.” Jeffries has found the process very engaging and feels it has given them a special sense of purpose. “It will be there for future generations. I think that is incredibly powerful.” Located in Seattle, Seattle Children’s provides healthcare for the special needs of all children. Seattle Children’s consists of Seattle Children’s Hospital, Seattle Children’s Research Institute, and Seattle Children’s Hospital Foundation. You can find out more about the Continuous Performance Improvement (CPI) program at Seattle Children’s, their CPI Outreach Program or their CPI book “Leading the Lean Healthcare Journey” at www.seattlechildrens.org. Some results from Seattle Children’s
A $20 million cost was avoided by being able to reduce square footage in designing a new ambulatory services clinic, by using CPI.
A $180 million cost was avoided by not having to build new patient rooms. A $2.5 million reduction was achieved in supply-related costs. A 3.7 % reduction in cost per patient was obtained, resulting in $23 million in annualized savings (adjusted for inflation). Patients see doctors sooner; there was a 50 % drop in appointment scheduling time. Fewer patients leave the Emergency Department without being seen during peak times. Patients spent 20 % fewer days in the Intensive Care Unit. Patients spent 20 % fewer days on ventilators. Patient time in the Inpatient Psychiatric Unit was reduced from 20 to 10 days and the unit can now accommodate 650 children a year compared to 400 previously.