Implementing lean: A hospital case study

Implementing lean: A hospital case studyImplementing lean: A hospital case study

An excerpt from Beyond Heroes: A Lean Management System for Healthcare.

Lean was a serious initiative from the beginning. It was energetically championed by our CEO at that time, John Toussaint, MD, who began his own lean investigations in 2002. By this time, I was a vice president with operational responsibilities in the hospitals for obstetrics, cancer care, and surgery, in addition to the philanthropic foundations, so I was involved from the beginning of our ambitious lean initiative.

Like many organizations beginning a lean initiative, we started by putting together teams to map our value streams.   First, though, we had to define “value stream.” In industry, value streams show how products and information flow through a company from raw material to fabrication and shipping. In health care, we decided, the patient was the product, and so the value stream would be the flow of a patient through a cycle of care. A cancer value stream, for instance, includes testing, diagnosis, treatment, and, some percentage of the time, hospice.

For women having babies, our obstetrics value stream began with prenatal checkups, continued through delivery, and ended with baby’s first visit with a pediatrician. In this way, we shifted our focus from organizing work around specialized departments (silos) such as pharmacy or surgery to organizing around the needs of the patient. We recognized that most patients flow through multiple value streams. Also, we learned that our first pass at any patient’s care was disease specific — not necessarily taking multiple health issues into account.

Next, we set end-to-end improvement goals in those value streams — cutting through departments and old barriers — and pushed ahead with three or four kaizen1 improvement teams operating every week across the organization. Our Friday report-out sessions were part information sharing, part tent revival. We trained more than two dozen people to become lean experts facilitating kaizen teams and then started rotating frontline leaders and executives through those facilitator positions for two-year terms.

Organizing all the work was our ThedaCare Improvement System Office, overseen by a senior vice president reporting to the CEO. We called our kaizen team weeks Rapid Improvement Events and made sure they were multidisciplinary, with nurses, patients, pharmacy technicians, family members, and doctors all joining together to solve problems. Wherever we applied lean thinking, quality was improving, costs were falling, and patient satisfaction was inching upward.

Like most of my fellow leaders, I saw the benefits of lean as the economy stagnated in the mid-2000s and cost pressures on health care increased. We had all seen plenty of improvement programs, but lean was the first that was a complete operating system, balancing the needs of patients, caregivers, and the bottom line. Lean thinking was helping us improve quality for patients, reduce costs, and engage employees like no other approach. About three years into this initiative, sometime in 2006, I was involved in improvement events in a cancer treatment value stream focusing on radiation oncology.

We were getting breakthrough results: improving labor productivity by 20%, improving same-day access to one’s doctor by 30%, and slashing the time it took to move a patient from diagnosis to treatment from weeks to days. After a slow start, physicians had become more engaged in lean and were sometimes driving improvement work. Patients were on every kaizen team, helping to shape and guide our priorities. Sustaining our improved processes was a struggle, but I was sure we would solve that problem, too. It felt like we were sailing with a strong tailwind.

Then we hit a snag that could have sunk our lean initiative. And the snag was us. What hospital executives were asking of our line managers was slowly strangling our lean improvement efforts. We were heaping on more work, expecting managers to guide lean efforts while performing the same managerial duties as before, in the same way as before. And we expected them to figure out how on their own. This was nothing new. Like our throw-her-in-the-deep-end training, these competing priorities were another strike against our leaders.  At the highest level, productivity at ThedaCare is defined as gross revenue per full-time employee equivalent. At the unit level, manager’s track worked hours per unit of service to define productivity. A unit of service might be a lab report, a surgery, or 24 hours in a medical unit bed.

One day, the very frustrated manager of a hospital intensive care unit yelled at me in my office (in a respectful Wisconsin way, of course), “You’ve changed the way our teams work, but you haven’t changed how we lead. We don’t have the tools for this.” Another manager wept in my office. Both of these were good and steady leaders, so I knew there was a real problem. I talked to other managers and to executives in ThedaCare’s two main hospitals and everyone recognized the truth of the ICU manager’s statement and acknowledged the general frustration.

Managers at ThedaCare are dead center — the bull’s-eye — of our leadership structure. They are responsible for frontline supervisors and entire units; they answer to vice presidents and other executives. New and daunting responsibilities were pressing down from above and below. It was no wonder that cracks were starting to show at this level. For nearly two years, we had been telling managers that the most important goal was improving patient experiences by improving the value streams they managed and then sustaining those improvements.

But we at the executive levels were still acting as if hitting monthly financial targets in the budget— mostly unrelated to improvement work — was the real objective. Goals were being generated in boardrooms, but these were often inconsistent with what was happening at the front line. Worse yet, we were failing to offer meaningful communication, training, or guidance to the line managers now responsible for keeping all the critical improvement work on track.

Kim Barnas is a former senior vice president, ThedaCare, and author of Beyond Heroes: A Lean Management System for Healthcare.

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  • guest

    Reviews of this writer’s healthcare system by actual employees contributing to Glassdoor–looks like they may still have some bugs to work out. Maybe use administrators who know more about the clinical work and less about the jargon.

    “Inadequate support of low – mid level management. Employees “heard” only when presenting ideas to improve organization. Significant favoritism in transfers/promotions. Constant changes in patient care areas are confusing for staff and don’t engender patient confidence. Due to changes in health care reimbursement, “no layoff policy” has created more liberal “termination policy”. Organization suffering growing pains.”

    “Too many upper management layers”

    “Advice to Senior Management – As you talk about Lean Healthcare it appears that there may be too much spending at the top and not enough “lean” there; as you can only take so much out of the people actually doing the work.”

    “There is a lack of listening to the staff when it comes to how to provide quality care to patients. There is a complete disrespect for work-life balance and threats of lay off if staff voice concerns.”

    “Advice to Senior Management – Listen to the people at the bedside. You trust them with the patients life but don’t trust their opinions on how to provide the best care.”

    “Advice to Senior Management – Many members of the management team are out of touch with the daily work. For them to better understand their staff, it would be helpful if they could have insight into an average days work load.”

    “The administrations attitude is it is their way or the high way. They tell you that you can be replaced. They encourage telling on your co-works. Even if it is something minimal. And the employee you tattle on could be let go for whatever you tattle on them for. Medical insurance is overpriced and has poor coverage.”

    • Dr. Drake Ramoray

      Both your points and the original article are poster children for why I won’t work for corp med.

      • guest

        Actually I thought the post really spoke for itself but couldn’t resist adding the Glassdoor comments.

        I mean, really, patients are “value streams?” The fact that she feels that it’s somehow acceptable to publish this stuff speaks volumes about the state of our healthcare system. As a patient I am offended, forget about my feelings as a medical professional…

        • Margalit Gur-Arie

          Yes, this post should be framed and posted in every physician lounge….

          Offended? I am petrified…. (just posted a minute ago )

          • guest

            Good post. Apparently Aldous Huxley was on to something. I take comfort in the possibly quaint idea that a lot of us will refuse to cooperate with providing our data to Big Brother. I personally am holding onto my Blackberrry for that reason, among others.

          • DeceasedMD1

            Nice piece Margalit. i have a new one for you. In Washinton Post there was a piece on a silicon valley company that is creating a microchip that one can swallow that is placed in the pill, in order to determine the level of compliance. With a smart phone it can be monitored. Suppose to be geared towards say the elderly. No doubt Big Pharma will have a filed day if this is even legal? Never mind if ther eis a PCP to monitor the efficacy. But the start up company exists. Kind of like Brave new World we’re here.

          • Margalit Gur-Arie

            Wait until they say that if you didn’t swallow your microchip on time, you’ll have to pay for all future medical services on your own because you just voided your “warranty” or something like that…

          • DeceasedMD1

            LOL. yes. something crazy like that. i was thinking more of how they have so much data.already but can’t get any more invasive than this. Big Pharma would love more compliance.

          • SarahJ89

            And they will, I assure you. I spent two decades being punished as a “non compliant” patient who refused pill after pill–nearly all of which were later recalled or had a black box warning. Turns out I was misdiagnosed all that time.

            This Brave New World of US medicine scares the carp outta me.

          • SarahJ89

            As a nearly elderly person who values her autonomy I commented on that piece. I was shocked to see how thoroughly anyone who values a modicum of privacy was trashed. It’s really frightening to see how privacy concerns are now no longer not even on the table, but are viewed as Luddite impediments to “progress.”

            My husband and I are moving to another country early in 2015, precisely because of this stuff. (Well, that and the fact it snows a lot here.)

          • DeceasedMD1

            You and i seem to think alike. It’s time to get out of Dodge as they say. THe luddite comment is right on. Soon we’ll be so advanced half of us will be dead from all this progress. (I think that was a joke but I’m not sure at this point.) I respect our European counterparts a bit more when it comes to privacy. At least they make an attempt. if i am not getting too nosy what region of the world are you looking at? I sure wish you the best.

          • SarahJ89

            Hi DMD,
            Ireland. I lived there in the early 70′s, felt very at home for the first time in my life. They had semi-socialized medicine then and it was great. I lived in northern Ireland also and their socialized medicine was awesome.

            I was raised by my Irish grandparents so I am ideally suited for Gilbert & Sullivan-era western Ireland. Which no longer exists. But I still feel more at home in Ireland than I ever have in the US. It has to do with the sense of time.

            This lack of any sense of privacy and the degradation of US healthcare as I age causes me to look east. We’re going over for a shakedown cruse this autumn. My family and friends over there complain endlessly about their healthcare system, but when we tell them what we pay they are appalled. Our Medicare will be useless there, but paying out of pocket for routine care will be cheaper than what we’re paying now. My husband will get a medical card when he reaches 70 (which is approaching like a speeding train).

            I worked as a geriatric social worker in a northern branch of Appalachia as a young woman. My clients were feisty, independent people. At the age of 25 I had to grapple with the fact that I wanted Mrs. X to be in a nursing home not out of any real concern for her well being, but so I could sleep at night. I spent a lot of my time after that reminding lots of people that these folks were adults entitled to make whatever stupid (to us) decisions they liked.

            Another reason to move to Ireland? If I’m ever stuck in a nursing home in the US the knowledge I will never get a decent cup of tea again would cause me to jump out the nearest window. This place is hell on a tea drinker.

          • DeceasedMD1

            you are quite humorous Sarah. I know what you mean about the tea here. Can’t you import it?
            I can relate to what you are saying. I don’t know if the care is better there, but at least I doubt it is out of the same kind of MIC we have here. And it is no doubt quite beautiful there. And yes nursing homes-well you seem very conscientious which is refreshing in this world. Well let me know what brand you drink of tea. I would love to sit and chat over tea. LOL

          • SarahJ89

            Barry’s. From Cork. I buy loose tea at an Indian grocery. But I’ve had to learn to drink coffee in self defense. No amount of explaining the need for *boiling* water will dissuade US food service folks from pouring hot water out of the Bunn-o-Matic, parking a tea bag next to it and proudly presenting it to the customer/resident several tepid minutes later.

            Yes, Ireland is beautiful. Parts in a wild and barren way and part in the more usual “forty shades of green.” I moved over there in my twenties because two people who knew me visited and wrote back “You should come here. There are people like you here. They never know what day of the week it is either.” I went over and felt right at home.

          • SarahJ89

            PS: What region of the US do you live in?

          • DeceasedMD1

            oh that’s pretty sweet. Your tea story made me laugh. It is so gross the way they make tea here. How hard is it to boil water? I am in California BTW.

  • SteveCaley

    Very simply, here is lean thinking, in the Warren Buffett model.
    WTFDYD? (What is YOUR job?)
    Healthcare: “I deliver babies.” “I take vital signs.” “I mop floors.” OK, so far so good.
    Also: “I implement six-sigma leanstreaming in management modeling for desiloification of the corporate cluster. I do value-added reciprocity
    modeling for just-in-time service delivery.” ????

    The ability to generate random jargon and feeble management concepts is NOT the missing piece of the puzzle. It IS the puzzle.

    We put Armani suits on these gorillas, so they can tell us why we are
    mediocre and need to work harder on the front line to turn a profit.
    Six-sigma, kaizen, yadda, yadda are not a medical terms; but fads of the
    self-preserving bureaucracy, under the myth that with enough fleas, you
    don’t even need the dog anymore. The EPA has a swell site on kaizen and how to do kaizening.

    I have been a manager of physicians and line personnel. I told them –
    “You are on the front lines fighting the war. I just bring you the soup
    and ammunition. What do I need to do to make YOUR job work?” A doctor on the front lines outranks me – so does a nursing assistant. They do things that make it all work – they are the ONLY ones that do.

    It is not “more important to listen to and integrate the input from the staff….” The staff are the ones that actually do the job. They are not helpful pets that tell us that Little Timmy fell down the well. They DO the job, everyone else THINKS about it. WTFDYD?

    There are trillions of words wasted on this simple concept. In actual, bullet-shooting modern warfare, it takes about seven supply personnel to make one combat person fully effective. And in every war, the seven, or twelve, or fifty support personnel get fat and mighty, and think THEY are the ones fighting the war. [ref. Napoleon, Waterloo] WTFDYD?

    When the French were kicked out of Indochina, they were a highly mechanized, battle-trained Army (see World War II) that was crushed by barefoot peasants on bicycles. [see Dien Bien Phu] I think that the Vietnamese ran about 3:1 for support-to-combat personnel – now, that’s “lean warfare.” Had the Vietnamese wished, nobody from the French Colonial Army would have survived; but the peasants were merciful. It’s not about whether Ho Chi Minh was a goodie or a baddie – it was that peasants got the point, and they won.

    The WTFDYD? test to the peasants would have showed that
    every one was contributing in a vital sense to the war effort. The
    WTFDYD? test to the French Army would show scads of
    useless work and workers.

    Back to American healthcare – We won’t get anywhere until we start asking WTFDYD?And we won’t. And we will lose, the same way that wars have been lost since time unrecorded.

    • DeceasedMD1

      Steve as usual you make your point in an effective but hilarious way. Maybe we can import those peasants on bicycles to help us.

    • SarahJ89

      Jargon = waste.
      Whenever I see posters in the hallway of a corporation with their “mission statement” on them I know they spent a ton of money hiring one of these upscale “facilitators” to waste an entire day of group time thinking up this basically meaningless exercise.
      The walls of our local “non-profit” hospital is plastered with this stuff. I shudder every time I see one, knowing the money wasted on it came right out of medical services.

      • SarahJ89

        Note: I’ve had the misfortune of being in one of those daylong sessions. The product? A paragraph of verbiage no one will ever look at. This was at least fifteen years ago and the facilitator was paid over $3K by the public agency that wasted the money.

  • DeceasedMD1

    would love to see her in her own hospital as a pt. Wonder if she might see things differently. But maybe not. THis is not the sharpest tack on the box. Never ceases to amaze me the endless propaganda.

    • guest

      We had this experience at my last hospital. The non-
      MD CEO was diagnosed with cancer and elected to be treated within our healthcare system. His experience was apparently not very good at all, no surprise to healthcare professional who worked there. His response? A draconian campaign to increase our patient satisfaction scores.

      In the case of our specific facility, which was a stand-alone behavioral health hospital, this meant the liberal provision of benzos and opiate pain meds to anyone who checked themselves in asking for them, as our facility had acquired a reputation in the community for being easygoing about such things. Holdouts for patient safely like myself were harassed about our low patient satisfaction scores. I was actually emergently paged out of a meeting with the family of a patient who had been readmitted following a bad outcome related to a discharge by another doctor. The purpose of the meeting? To show us a video instructing us to “introduce yourselves to your patients by saying “Hi! I’m so glad you’re here!”

      Docs who went along with this nonsense were rewarded by patient deaths via in-house overdoses, followed by lawsuits and disciplinary actions.

      I was the first to leave, as I feared for my license, but subsequently so did almost every other MD on staff. Last I heard the hospital is staffed almost exclusively by locum tenens, since no one else will work there.

      • DeceasedMD1

        Well it just warms the heart. (eye roll). Both examples are great illustrations of how pay for performance or increasing pt satisfaction scores, are actually killing pts. But let’s continue, so I can make my next bonus and make everyone happy while I deny that pts are dropping like flies around me. But the living ones are very satisfied.

        First of all I thought there were no psych beds left in the country except in prison. SO how the heck does this psych hospital stay in business? And more to the point, how do they get away with this? So the docs are the fall guys and the hospital played no part in the lawsuits?

        And best of all, the illness (I assume in this case drug addiction) is running their treatment plan. And your job has turned from doctor to become some sort of greeter since you obviously need help with communications skills. LOL. Oh and I guess you were supposed to be the designated drug dealer. Good for you. Run for the hills! I hope you have a better job now.

        • SarahJ89

          I refuse to fill out patient surveys, knowing they will only serve to enrich the administrators. And also knowing the metrics I’d need access to in order to make a relevant assessment will continue to be withheld from me. As long as all I’m allowed to comment on is the nice doctor’s bedside manner and how lovely the curtains are I will continue to toss those wee buggers into the trash.

          As for how a psych hospital stays in business: follow the insurance money. Whatever fad is going on in mental health will be there “specialty” du jour. Drug addiction is a good choice because all you have to do is provide legal Coke as you take away their illegal Pepsi. Viola! High patient satisfaction scores.

          Want to be cured of your mental illness? Just run out of insurance when you’re in a psych hospital. You’ll be out on the sidewalk, “cured” before you know it.

          • DeceasedMD1

            The thing is insurance money I believe is non existent for psych, especially inpatient–or extremely limited.. Prior to the ACA i was offered an insurance plan that had zero mental health or substance abuse benefits. I did not think the plan was legal for that reason but who knows? I still don’t know if all plans have to cover mental health at all. I think it is a state decision but not sure.

            I like your reasoning as I bet many of these places should be shut down, But every time I read anything on mental health, the answer is there are no beds except in prisons. Did you hear about Creigh Deeds the senator in Va. who had a son that was held in an ER but they let him go because they could not find any bed for him. He was released and killed himself and shot the attacked his father sho is I believe senator in Va.
            I think you are spot on as far as how that works in psych hospitals, but i don’t think there are any left that have long lengths of stays. The average in my area I heard once was 3-5 days but that was several years ago. And for the severely mentally ill, prison awaits.

          • SarahJ89

            It depends on the money. There are fewer places, but the few left are making just as much money as ever. They continue to effect Magic Cures when the money runs out.

            I work on a farm that takes in some boarders. One of our boarders is a woman with an eating disorder. She found a place in CA only too happy to help her drain her retirement account (at one time she had a very good career–it’s a very sad story). She was there for four months, came back with her retirement nicely drained. She now faces a penniless retirement with an eating disorder.

            Medicare used to pay 190 days lifetime for psych hospitalization, don’t know what the policy is now. I would have told her that but it was clear these sharks were going to drain that retirement money once they got her there. I took care of her dog for four months instead.

          • DeceasedMD1

            that is pretty tragic. I was unaware there were any psych hospitals that even treat eating disorders that are still open in california. Was it in southern or northern california if I may ask?

          • SarahJ89

            I don’t know. I’ll try to remember to ask her when I get back to work. My sweetie and I have had two viral infections, one on top of the other, which has had us out of commission for three weeks. He’s an accountant and I keep the books on this farm. We’ve been swapping off–whoever feels up to it on that day goes in. I do the payroll remotely no matter where I am, though–sick in bed, in a car in Dublin rush-hour traffic, rolling across a barren bog, in the woods. I’ll probably be doing the payroll in my coffin.

          • DeceasedMD1

            wow sounds like death and taxes! LOL. I sure hope you feel better. keep drinking tea. Sounds lovely living on a farm minus the book keeping.

          • SarahJ89

            Actually, for some peculiar reason I love doing payroll. It involves a lot of rote fiddling with an Excel spreadsheet that I find soothing. I have no idea why. We’re better now and I’ll be going in this week. Just in the nick of time, too. I have to revise a grant application that’s due on Wednesday. I thought my brains were never coming back, but here they are!

          • DeceasedMD1

            oh fantastic. Well nothing like feeling better and feeling productive!

      • Teresa Brown

        Liberal benzos and opiates? Throw in some Cheetos and some cheap wine and you’ve got yourself a party.

  • medicontheedge

    The last paragraph is the sum and the tell.
    Consulting: Spending a dollar to save a nickel.

  • SarahJ89

    Wow. Just what I’ve always wanted to be: a product, a widget on a factory assembly line.

    This article demonstrates precisely why meshing medicine and corporate thinking is such a bad, bad idea.

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