Health system builds on success with Lean
Health system builds on success with Lean
Employees involved in decision making
In its sixth year as a Lean organization, MemorialCare in Southern California refers to Lean as its management system, not a quality improvement method, says Diana Hendel, Pharm.D., CEO of Long Beach Memorial Medical Center, Miller Children's Hospital and Community Hospital — both also of Long Beach. While she acknowledges that some people find it odd to take a system used in manufacturing and use it for healthcare, there are similarities in process flows.
Like Denver Health, MemorialCare hadn't changed the way things were done in a long time. "The value to the patient wasn't always considered," Hendel says. That has changed.
The biggest impact she likes to talk about came at Long Beach Memorial Medical Center, one of the busiest level-two trauma centers on the West Coast, with some 100,000 visits per year. The average wait time for a patient to be discharged was about six hours. Within a week of taking on the project for rapid improvement, that was down to less than four hours. For patients who are admitted, the wait time could often be up to eight hours to see a physician, while the best hospitals manage that in three.
They looked for bottlenecks for patients who were being admitted or discharged and found that the usual process — to triage the patient first through a nurse, then through admitting, and then for another screening before seeing a physician — was rife with waste. They decided to reverse the order. Now a physician sees the patient first, making earlier determinations on whether the patient needs to be admitted or can be sent home, says Hendel.
Tamra Kaplan, Pharm.D., COO of Long Beach Memorial, says another great Lean project worked on physician-to-physician communication. "If you want to call an attending physician or a hospitalist to warn of an impending patient, you would often have this tag team of phone calls between them and their offices or answering services," Kaplan explains. The solution: Give all attendings and ED physicians cell phones so that there is direct contact.
Kaplan had a background in Lean, which was critical to the success of the program, says Hendel. Now, all managers go through the training, which Kaplan says you can tell just by listening in on conversations. "All our vocabulary is around Lean. We have visibility boards in most departments that talk about current state, target conditions, and barriers."
Employees are incredibly engaged in Lean, Kaplan says. "We are allowing them to be involved in the decision making that transforms what they do every day. We can solve difficult problems quickly because now we have a methodology to figure out a different way to do things."
This isn't a short-term project or campaign, says Hendel. It's not something you do on the side. "This is our management system, our way of thinking. We believe in it because we have seen the 70 workshops we have done eliminate a tremendous amount of waste. That converts to value to the patients. It is a journey. It is small steps leading to big change."
Lean isn't for everything. There are elements of change in the system that are governed by other management techniques. But Hendel says if there is something involving a large number of people — the OR, ED, patient flow — Lean works well.
Unity Health in Rochester, NY, has been using Lean for five years now, says Catherine Lee, MS, MT, a Lean Six Sigma Master Black Belt and director of operational process improvement at the system.
She doesn't rely totally on Lean as a system for change, but, as her credentials imply, also uses Six Sigma, as well as change management. But what Lee likes about them all is that they have a set of tools that can be applied in a disciplined way to create great improvement.
Lean isn't used just in the clinical arena at Unity, but across the system. Its success is largely predicated on the quality and nursing departments agreeing to give it a try, Lee says. "Their openness to try something different was there, even though people kept telling me that people aren't widgets." More than 100 projects later, the early successes led to much greater acceptance of Lean.
"If you can get a few champions and a few targeted projects where you can build on success, you'll be able to bring people on board," says Lori Lewandowski, RN, quality improvement and public reporting coordinator at Unity Hospital.
One of the early successes was a reduction in door-to-balloon time for percutaneous coronary intervention (PCI). The Joint Commission wants to see a 90-minute door-to-balloon time. With processes Lewandowski calls "all over the map," the average time at Unity was 110 minutes.
"Lean was a great choice for this because we could look at timed events that happened in sequence through the journey from the ED to the cath lab," Lewandowski says. They looked at several steps: door to EKG, EKG to provider notified, provider notified to cath lab, cath lab to balloon. Using value stream maps, they looked at what happened within each process. In the end, they cut the door-to-balloon time by 17 minutes.
Among the issues uncovered, Lewandowski says, is how patients are triaged and whether they were casting too wide or too narrow a net for patients. They found that physicians were using their watches to mark down time, when one watch might have a different time from another. Now they all use the same clock. She says they implemented a pull system, so that when the cath lab was ready, if the patient wasn't, they would go to the ED to see what they could do to prep the patient so they weren't standing around waiting. They implemented standardized education for reading EKGs and a new process for when to call the interventional cardiologist. "We used to have a process where the cardiologist on call would be called first, and he or she would determine whether to call the interventional cardiologist. But the interventional cardiologist is the one who makes the call."
There is signage in the ED reminding everyone who to call, and a way to get an EKG faxed to a physician at home if necessary. But Lewandowski did bring elements of change management into the program, too, as a way to modulate the communication between physicians. "We are always looking for more minutes," she says, noting that CMS wants to see the door-to-balloon time move to 60 minutes eventually. "We do this consistently well, now, and most of our cases are within range. But there are still some differences and things we need to tweak. We look after every case, and when there is an outlier, we do a root-cause analysis."
She says there will always be people who don't want to follow a new course, but it's much easier to convince them if the process is endorsed from the top down and if you have some early successes you can point to. "It can take time to embrace change," says Lewandowski. "But we have had some great projects because of this."
For more information on this topic, contact:
- Tamra Kaplan, Pharm.D., Chief Operating Officer, Long Beach Memorial Hospital, Long Beach, CA. Email: [email protected]
- Diana Hendel, Pharm.D., Chief Executive Officer, Long Beach Memorial Medical Center, Miller Children's Hospital Long Beach and Community Hospital Long Beach, Long Beach, CA. Email: [email protected].
- Catherine Lee, MS, MT, Lean Six Sigma Master Black Belt, Director of Operational Process, Unity Health, Rochester, NY. Telephone: (585) 368-4436. Email: [email protected].
- Lori Lewandowski, Quality Improvement & Public Reporting Coordinator, Unity Hospital, Rochester, NY. Telephone: (585) 723-7000.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.