June 3, 2010
I recently visited the Thedacare Center for Health Care Values in Appleton, Wisconsin. Thedacare is a two-hospital health system that incorporated lean process improvement initiatives a few years back in response to what ails every single hospital in the country: waste.
Lean, as some of you know, is a management strategy originally devised for Toyota to improve efficiency. It is widely credited with making Toyota the leading car manufacturer in the world, a position it still owns despite its recent troubles.
The definition of lean is deceptively simple: "the relentless pursuit of the perfect process through waste elimination." Every process has its defects that produce waste. Car manufacturing, drug delivery, operating-room times, hospitalist rounds, your household budget, your marriage: Any process that involves people can be made more efficient and less wasteful. Lean emphasizes value-added activities, which are defined as "any activity that changes the form, fit or function of a product or transaction." Everything else is waste and must be rooted out.
I visited Thedacare because my health system has embarked on the process of continuous improvement. It has done so because times are tough and will only get tougher. Health care will continue to be an expensive proposition, and reimbursement for our services will not improve. So the best way to tackle this budgetary imbalance is to improve the way we do things. Efficiency decreases cost, improves the product we deliver (health care) and will make our patients better. Isn’t this our mission, after all?
Thedacare began this same process a few years back, and while they say their efforts are still in their infancy, I was amazed at how much they had accomplished. Their strategy, "measurably better value" for their patients, is apparent in the multiple tactics they use to decrease waste.
These changes come not from executive fiat but from the workers: the nurses, physicians, cafeteria workers, secretaries, patients (yes, patients! How truly patient centered!)—every person in the system can "pull the cord" to stop a process and initiate an improvement cycle.
Those "experiments" are celebrated at a "report out" meeting every Friday, in which the teams that worked on an improvement project present their findings to their colleagues. For example, a team reported their efforts to decrease the amount of time patients spent on hold trying to reach a nurse at a clinic. Another team reported on how they decreased the wait time for breast cancer biopsy results to the same day! It was standing- room only when we went, and apparently it is so every week.
A process improvement cycle begins by identifying a process defect and stopping it, then analyzing its root cause and implementing a way to standardize the process improvement. Lean comes with a whole set of linguistics: acronyms, initials, coded terms. One of the frameworks for change involves the A3 process, which breaks down the PDSA cycle. PDSA stands for:
- Plan: Determine the problems with current conditions and goals, as well as needed changes. This is the hypothesis.
- Do: Try out the changes. Experiment with the changes you've proposed.
- Study: Analyze the results of those experiments and reflect on what you learned. See if the changes work, and tweak them as needed.
- Act: Incorporate the new learning or knowledge into the process and work to standardize the change.
At Inova, we are in the early stages of becoming lean. As I alluded to in my previous column, we have launched initiatives to decrease the emergency room-to-inpatient-unit transfer time and discharge time, and to improve communication of discharge criteria and plan of care.
And we recently made a value-stream map, a diagram of every step involved in the delivery of care to our patients. The team making that map included nurses, doctors (both attendings and residents), pharmacists, respiratory therapists, child-life specialists, housekeeping and a patient representative, among others.
In all, we identified close to 100 areas for improvement, 100 opportunities to reduce waste—and that was at first glance. There are much more wasteful processes that we didn’t even consider. But part of the culture of continuous improvement is that it is a journey without an end. There will always be opportunities to do better.
To learn lean is to learn a whole different language, and become part of a different culture of change. We are always afraid of change, but we know that the status quo, the current state of health care, is unsustainable. Our leaders have the vision and the courage to embark on this journey because it is the right thing for our patients.
Whatever paths you take toward continuous improvement, always keep that in mind: We're doing this to improve the health of our patients. That's the only way to produce a truly patient-centered health system.
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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is a pediatric hospitalist. A veteran of both community and academic
pediatric hospitalist programs, Dr. Nazario weighs in on the challenges
of daily pediatric hospital medicine practice.