Many organizations have reaped the benefits of adopting Lean concepts, such as greater workflow efficiency, staff engagement, and cost savings. After initial improvements are made, however, it can be hard to sustain the process changes over time.
That was the case at Nemours A. I. duPont Hospital for Children in Wilmington, Delaware. A successful Lean initiative had cut day of surgery wait time from an average of 128 minutes to 78 minutes, and reduced the number of steps for transitioning patients from the preoperative holding area to the OR from 95 to 33.
The multidisciplinary project teams seemed poised for more change and more progress. But in the middle of 2013, the teams hit a roadblock.
“We had change fatigue,” says Dee Tinley-Strong, PhD, MA, process engineer and value stream manager for perioperative services at Nemours. “The data showed that there was still too much variation in practice and that the process changes weren’t stabilizing.” Although one of the goals had been to boost patient and family satisfaction, those numbers had improved only slightly.
Tinley-Strong refers to the experience as the team’s tipping point. “We needed to take a time out and regroup,” she says. A team consisting of senior directors, perioperative services managers, and OR model line medical sponsors visited other pediatric hospitals that had been working with Lean for a number of years, but the most enlightening visit was to an industrial setting, where team members heard about the integrated systems approach to Lean.
“We learned you don’t need a 3-day assessment or a 5-day workshop [which occurs with the traditional Lean approach] to implement change,” she says. “You can make changes in a focused event that could be as short as 4 hours.”
Back at Nemours, further analysis revealed two core issues: failure to integrate existing cultural values into the work and using a discrete, event-based model within a systems-thinking organization.
Here is how Tinley-Strong and her colleague, Sharon Udy-Jan-czuk, MSN, RN, CNOR, OR nursing manager, worked with team members to correct those issues and put the Lean initiative back on track. Their efforts led to $1.7 million savings in labor and materials over an 18-month period and a reduction in cost per case for selected procedures, including a 50% reduction in laparoscopic appendectomy costs.
The team at Nemours realized they had been sending conflicting messages to staff. For example, trying to eliminate waste was sometimes at odds with the philosophy of doing “whatever it takes.” Tinley-Strong says, “We had emphasized staff should do ‘whatever it takes,’ but that means whatever the patient needs or wants—not what staff want.” Leaders refocused staff and fine-tuned education about Lean to include more healthcare, rather than industrial, examples.
Independent thinking and freedom to practice vs reliable methods and standard work was another contradiction. “We still struggle with that balance,” Tinley-Strong says, adding that transparency in communication has been essential to help achieve balance and to engage previously resistant staff.
To help address contradictions, “we worked on enterprise-wide guiding principles to fully integrate values,” Udy-Janczuk says. That included identifying “True North” drivers, ie, goals to take the organization forward, which required multiple meetings with key stakeholders.
“We realized we needed to be on point with quality, safety, delivery, and cost—these drivers needed to be done in the right order so we’d all pulling in the same direction,” Tinley-Strong says. “If we do the right things for our clients, we’ll achieve results.”
Inadequate education about Lean had led to resistance because some staff felt the initiative was more about saving money than the value of patient care and safety. To correct that misconception, the team increased the amount of education given staff when Nemours moved from an event-based model of change to an integrated systems model.
Tinley-Strong says the integrated systems model provides three key advantages over the traditional, event-based model of Lean:
• The systems model takes into consideration the culture of the OR and recognizes that total standardization isn’t possible, or even desirable. “We want staff to rely on evidence-based thinking and their critical thinking abilities,” Tinley-Strong says. “We don’t want to take away from that.”
• One size doesn’t fit all. By focusing on one distinct problem to solve in one unit, for example, the event-based model may inadvertently create a problem in another unit. “It’s like Whack-A-Mole,” Tinley-Strong says. “I might whack a mole in preoperative holding, but create another mole in the PACU [postanesthesia care unit].”
• The event-based model emphasizes rapid change, but sometimes it can be too fast. The integrated systems model allows time for changes to stabilize, so that staff and customers become accustomed to the new workflow.
An integrated systems model requires asking two key questions: “What (not who) caused this to happen?” and “How will this proposed change impact…?” It’s also vital to view patients and families as the organization’s customers and to always lead with, “What is best for the patient (not what is best for me)?” say Tinley-Strong and Udy-Janczuk.
A successful integrated systems model requires high-performing multidisciplinary teams to do the work. “They have to be cohesive and collaborative, and they have to be empowered to implement and maintain changes,” Udy-Janczuk says.
All stakeholders affected by the process being examined are represented on the teams, which are facilitated by the executive leadership team. She summarizes the focus as CCLEEAR—collaboration, communication, leadership, expectations, engagement, accountability, and responsibility.
Educating the teams before they went to work included explaining the integrated systems model in terms of the patient’s perspective. “We would tell them, ‘This is where we are, this is where patients and families would like us to be, and this is the process to get there,’” Udy-Janczuk says.
Teams of stakeholders from various departments work on problems that interfere with patient flow or could affect patient safety and track trends to identify future projects.
“We encourage them to look at the big picture and not just to take a Band-Aid approach,” Tinley-Strong says. That philosophy helps avoid the silo approach and problems in other departments.
Members use the plan-do-check-act and a practical problem-solving approach that includes the following steps:
• Problem impact: So what?
• Problem perception: I think this happens because…
• Clarification: The evidence says…
• Locate area/point of cause: Where?
• Root cause: What are the direct causes (process, design, conditions, equipment, methods, individual performance)?
• Countermeasures: Solutions.
• Evaluate results: Track outcomes.
• Implement changes: Respond to the data.
An example of a problem statement is as follows: Sterile processing department case cart arrived in OR 6 with two trays missing; this has happened three times in the past 2 weeks. To resolve the problem, the team quickly pinpointed the need for a more robust rapid turnover process for loaner trays and one-of-a-kind trays.
An integral part of the integrated systems approach is the daily management, which includes tiered huddles. “We use the MESA system—method, equipment, safety/supplies, associates [employees] as a framework for what we discuss,” Tinley-Strong says.
The safety and readiness huddles are held at 7:05 am, 7:30 am, 8:00 am, and 8:50 am. These huddles include leadership, physicians, perioperative managers and staff, and representatives from ancillary support services.
The 7:30 am huddles, which take place in individual ORs, include the surgical technologist, circulating nurse, surgeon, and anesthesia provider. These huddles focus on the needs of the patients in the individual ORs.
Issues that require support at a higher level are reviewed in the 8:50 am perioperative readiness huddle, which includes the senior director of perioperative services and managers from preoperative holding, OR, PACU, day medicine, gastrointestinal, sterile processing department, and process engineering.
If an issue needs even more support, it’s discussed in the 9 am huddle, which includes managers of every nursing department in the organization, as well as representatives from areas such as biomedical engineering, materials management, pharmacy, and laboratory. In some cases, the issue might need to be discussed in the 11:30 am executive huddle.
Gemba walks are also a part of daily management, with managers from perioperative services (and sometimes managers from support services), assistant managers, and Tinley-Strong walking through all the perioperative service areas to review the huddle boards. The daily 1:00 pm Gemba walks help the team detect problems that are occurring in more than one area.
Other advantages of Gemba walks and other efforts include enhancing leader and manager visibility, promoting accountability, role modeling desired behaviors, and responding promptly to patient flow, safety, and staff needs.
Issues are tracked on management white boards and reviewed during huddles and the Gemba walk. Every issue is assigned a due date, a resolution owner, and at least one initial countermeasure. Issues that can’t be resolved within 24 to 48 hours are escalated as complex problems to be addressed by leadership. To close the loop, leaders take action and report the status during unit huddles and the Gemba walk.
Leaders create their daily Lean standard work practices by using a trifold tool. Their personal trifold is developed on one piece of paper that contains a matrix of daily, weekly, and monthly accountabilities. Using the tool helps leaders to stay on track.
In addition to daily management, leaders also strive to enhance staff performance (sidebar).
Metrics are based on the five True North drivers. The OR model line management guidance team, composed of vice presidents, executive officers, and sponsors, tracks progress on the True North metrics (first case on-time starts, OR case turnover, surgical site infections, cost per case, and likelihood of the patient recommending the hospital) through monthly updates of Strategy A3s. Strategy A3s are one-page documents that contain an array of data drilldown reports, barriers, and countermeasures for overcoming those barriers.
Metrics for individual units such as the OR and PACU are updated daily, weekly, and monthly, and are posted on the daily management boards where all staff can see them. These metrics are reviewed during huddles and Gemba walks.
Metrics have shown how the integrated systems approach has led to substantial financial savings. For example, the 50% reduction in cost per case for laparoscopic appendectomy occurred through standardization of disposal supplies used by all surgeons performing the procedure.
Another success story is streamlining the clinical workflow within the preadmission testing clinic. The improved workflow also increased patient satisfaction by eliminating extra presurgery clinic visits and increasing the rate of day-of-surgery history and physical from 34% in 2013 to nearly 95% in 2015.
Redesigning this process in 2014, along with previous process improvements within perioperative services, produced financial gains totaling approximately 6.5 full-time equivalents.
Successful implementation of the integrated systems approach to Lean depends on leaders learning the system and providing education to staff.
“You want to know as much as you can about Lean, human behavior, and how to support the process before you start,” Udy-Janczuk says.
Tinley-Strong adds that part of any Lean approach is knowing when to push the pedal of change and when to ease up. “When you first start, everything can move ahead very quickly, but it’s unlikely you’ll be able to keep up that pace,” she says. “You have to know when to slow down so that people won’t give up and withdraw.” ✥
Redlinger R D, Udy-Janczuk S, Tinley-Strong D. Systems thinking and Lean transformation: An integrative model for the operating room. OR Business Management Conference 2015.
Interested in learning more about business management of the OR? Register for the 2016 OR Business Management Conference! Learn more here.