Special Report

Learning to be Lean
Sabriya Rice

A hospital's staff discovers improving efficiency isn't easy


On a Wednesday morning early last month, a dozen nurses, housekeepers, surgical technicians and surgical assistants at Presence Health's Sts. Mary and Elizabeth Medical Center are running behind in their hunt for ways to save time on the hospital's busy surgical floor.

While others performed their usual duties, the group, surrounded by a conference room wall full of brightly colored Post-it notes, is midway through the challenge handed them by the hospital's leaders. They are spending a full week observing their colleagues' actions between surgeries to identify inefficiencies and come up with recommendations for an improved workflow.

On this third day, Maria Vela, peering at the wall with one hand on her hip and the other on her chin, suggests surgical technicians like her be given the task of carting new patients into the operating room. Nurses, who usually perform this task, are too busy inputting patient information into the electronic health-record system and grabbing supplies to restock the rooms, she says.

“They would refuse, even in an experiment,” counters Jackie Kostakes, the nurse on the team. Nurses need to verify patients' identities, a key part of maintaining patient safety, she argues.

At the beginning of the week, the people in the room barely knew each other. Some had never talked publicly about their tasks in the hospital. Now they are quarreling over how to reduce turnaround times on the eight-suite surgery floor, which could run as long as an hour — from an average of 30.55 minutes down to 25 minutes.

Paresh Parikh, a surgical assistant, throws more cold water on Vela's suggestion. The surgeon needs to talk with the patients first to ensure the correct body part is marked for the surgery, he says. “It wouldn't work.”

The tension in the room mounts. The team needs to generate a final list of solutions by the end of the day. Every proposal seems flawed.

Maria Vela
Steve Siver

Boosting employee engagement

The tactic being used at Presence — where frontline workers spend a week brainstorming how to identify flaws in a production process — is known as a breakthrough rapid improvement event. It is part of the Lean quality improvement method now in use at a number of hospital systems across the U.S.

Sandra Bruce, CEO of Presence Health, launched the 11-hospital system's Lean initiative in 2012 to boost employee engagement in its efforts to slash inefficiencies that hindered the delivery of high-value care. The OR turnaround time initiative is the hospital's seventh rapid improvement event specifically aimed at perioperative services.

Over the course of the week, which was observed by a Modern Healthcare reporter, the discussions among team members become more candid. Complaints about less productive staffers are aired. A staffer claims older workers are less proficient working with electronic health records. Management has not spelled out clear job roles for everyone.

Each problem is written on a Post-it note and stuck to the wall of the war room, where team members gather between each day's worksite inspections. “We're going to need a lot more Post-its,” jokes Marj Welchans, as she searches for an empty spot on a wall lined with hundreds of the colorful pieces of paper. Welchans, who works as a facilitator at Presence Health's United Samaritans Medical Center in Danville, Ill., is what the Lean team calls the “outside eyes” — a staffer who does not work in the surgery department.

The impasse between Vela and her co-workers is not uncommon during Lean process improvement work. Over the course of the rapid improvement week, team members try some things that work and others that don't. They keep tinkering, hoping to muddle their way to a more efficient way to handle patients, provide treatment and manage supplies. While they will have an opportunity to revisit and refine those processes in the following months, the streamlined processes are slated to begin the following Monday.

“We design the new world.” Ronald Guidizi, Faciliator Throughout the week, Lean team facilitator Ronald Guidizi, a former nurse who now works as one of 35 “breakthrough improvement” facilitators employed at Presence hospitals, stresses that it's all up to the team members. “We design the new world,” he tells them in a message that's both encouraging and intimidating.

Steve Siver

Greater efficiency, higher quality

Hospital management has the ultimate responsibility of figuring out how to make facilities operate at greater efficiency and higher quality. But under the Lean method, staff members more accustomed to taking orders from their bosses must learn to overcome their trepidation about speaking up and accept responsibility and authority for driving changes in their workplace.

Baylor Scott & White Health, Denver Health, Virginia Mason Medical Center, ThedaCare, Group Health Cooperative, Seattle Children's Hospital, Massachusetts General Hospital and Emory Healthcare are among the health systems that have adopted Lean methods to redesign clinical and business processes. The improvements developed by the Lean teams vary, but they generally seek to create standardized protocols, eliminate waste and develop cultures of continuous improvement that allow hospitals to adapt to the changes now sweeping across the healthcare delivery system, driven by incentive programs such as value-based rewards and penalties.

Lean by example But despite its proven results, a limited number of health systems are using Lean methods. It requires the commitment of time and resources. It is also proving difficult to get some hospital and physician leaders to embrace the Lean approach, which relies on engaging lower status front-line staff in problem solving.

“The way they have done business for their entire career is turned completely upside down,” says Dr. John Toussaint, who introduced Lean principles when he served as CEO of Appleton, Wis.-based ThedaCare from 2000 to 2008. He later launched the ThedaCare Center for Healthcare Value, which educates healthcare executives on Lean implementation.

“I was floored by what they came up with. It really demonstrated to me the power of giving the teams the gift of time to make the work better.” Martin Judd, CEO Sts. Mary and Elizabeth Medical Center Nearly 60 healthcare organizations that use Lean share best practices through the group's collaborative network. Its annual conference in June drew representatives from more than 300 organizations.

Martin Judd, CEO of Sts. Mary and Elizabeth Medical Center, acknowledges he was skeptical when he and other Presence leaders were asked to participate in a two-day Lean breakthrough event last fall. “I drove the team crazy,” he recalls. “I did not want to be there.”

But after seeing the outcomes of breakthrough events at other hospitals in the Presence system, he is now an enthusiastic supporter. “I was floored by what they came up with,” he says. “It really demonstrated to me the power of giving the teams the gift of time to make the work better.”

Bruce, who steps down as Presence Health's CEO on Oct. 1, started the Lean initiative the year after Presence Health was formed by the merger of Resurrection Healthcare and Provena Health. She says frontline staffers know how to solve problems, but too often are never asked. And when they have offered solutions, leaders have not listened.

“The engagement level and morale of employees is higher when we bring them into the performance-improvement work, let them describe the problems, seek out the data and come up with solutions,” Bruce says.

Steve Siver

Creativity and skill

The Lean methodology was developed by Toyota Motor Corp. as part of the automaker's vaunted Toyota Production System. Like other total quality improvement methodologies such as Six Sigma, Lean was picked up by U.S. manufacturers more than three decades ago. Only in the past decade has it found its way into the healthcare system.

The beauty of Lean is that it engages the creativity and skill of the front-line staff doing the day-to-day work, says Mark Graban, a Dallas-based consultant and author of several books on Lean. “It's much more effective than someone saying, ‘I'm going to come fix it for you.’”

Health systems using Lean take different approaches. Some hire outside consultants. Others, like Presence Health, have hired their own Lean facilitators. Some are just “dabbling here and there,” while others have committed to transforming their organizations through systemwide Lean process improvements, Graban says.

Application of Lean in healthcare continues to evolve. Rather than routinely pulling staff away for weeklong rapid improvement events, Dallas-based Baylor Scott & White Health now limits such events to major initiatives. Instead, everyone from top leaders to cleaning staff participates in daily huddles to identify and implement improvements. “Every single day, every person has the ability to bring forward an idea that can close the gap, without having to participate in a big event,” says Steve Hoeft, Baylor Scott & White Health's senior vice president of operations excellence.

Kathleen Long, Presence Health's director of breakthrough improvement, says one of the biggest challenges to overcome in Lean implementation is the commitment of staff time. “Health systems are so incredibly broken, but nobody takes the time to step back and say, 'Does the way we do this make sense?' ” she says.

“Health systems are so incredibly broken, but nobody takes the time to step back and say, 'Does the way we do this make sense?” Kathleen Long, Director of Breakthrough Improvement Presence Health “The engagement level and morale of employees is higher when we bring them into the performance-improvement work, let them describe the problems, seek out the data and come up with solutions,” Bruce says.

It can be time consuming for top system leaders as well. At Presence Health, they attend two-day leadership events to decide which specific operational areas such as revenue cycle, emergency department, and supply chain have opportunities to boost efficiency and save money. The hospital leaders pinpoint areas where time or resources are being wasted, and plan monthly rapid improvement events in which front-line staff tackle manageable chunks of problems.

At Presence's Sts. Mary and Elizabeth Medical Center, the six rapid improvement events that preceded the OR turnover time event all focused on perioperative surgery services that had been identified by management as areas where process improvement could generate enormous savings. Earlier events tackled inpatient preparedness for surgery and completing checklists prior to the patient reaching the holding area.

Each rapid improvement event involves a nine-step, problem-solving process that includes analyzing the workflow, crafting new goals and processes, identifying gaps that inhibited them from reaching the goal and devising experiments to test the changes.

The problem the surgery unit team was asked to address in August was the excessive time for cleaning, disinfecting and restocking the ORs after an operation. The slow turnovers delayed procedures, frustrated patients, physicians and staff, and reduced the volume of procedures that could be performed, thus cutting hospital revenue.

“Surgery is both a high cost, high-profit department so it makes good business sense to effectively manage the expensive resources,” Long says. “Freeing up 6.5 minutes per case has the potential to add $600,000 of added revenue over the course of a year.”

But freeing up those minutes is proving to be a tougher task than many on the Lean team anticipated.

Steve Siver

Seeking solutions

The event's first day is devoted to the team learning about Lean thinking and visiting the workspace for the first time as observers.

On day two, they follow colleagues doing their normal work, get a sense of the challenges and begin devising solutions. The team hits the surgery department floor armed with floor maps, stopwatches and notepads.

When hernia, joint replacement and cyst-removal operations are completed, some team members run to keep up with staffers moving from the OR to supply storage closets, to the patient holding area, and to other locations. They time how long it takes.

Some staffers stop to offer insights. Others seem irked by the observers. “Holy cow! It was dizzying,” Andrea Ramel exclaims at the end of the second day. Ramel is training to be a breakthrough improvement coordinator at the system's St. Joseph Medical Center in Joliet, Ill.

Surgical tech Vela notes the tremendous amount of variation in the room-turnover process. Team members find that completed patients are sometimes carted to the recovery room by a nurse and sometimes by a surgical assistant. EHR information sometimes is charted before patients leave the OR and sometimes after. “We need a repeatable process,” Vela says.

If the next surgery involved a medical device, the manufacturer's representative has to be found and brought to the room. But Emily Manning, an intern in the hospital's administrative department who participates on the Lean team, observes that it is hard for nurses to coordinate the arrival of the new patient and simultaneously track down the manufacturer's representative.

There also are problems with storage of surgical supplies, which sometimes have to be retrieved from another floor or are missing entirely. Nurse Kostakes says some staffers voluntarily come to work an hour early just to pull these supplies together ahead of time.

That type of heroic effort, where highly motivated staffers develop workarounds in a broken system, is a classic red flag, says Lean expert Graban.

Kostakes points out that some nurses aren't used to working on computers, slowing EHR entry time. Note cards listing the supplies surgeons prefer to use are handwritten and are rarely updated, Vela says. Sometimes supply trays are stocked and sometimes they aren't, observes Juliette Ahanobi, a sterile processing manager on the team.

observations SABRIYA RICE Armed with floor maps, stopwatches and notepads, the breakthrough team at Presence Health followed colleagues to see if the changes they suggested were having an impact

But the Lean team's most surprising and perplexing observation is that when surgical floor staffers are followed by the team, they consistently perform room turnover in 18.4 minutes, more than five minutes faster than the target goal of 25 minutes. The finding suggests that the turnover time goal could be met if staff members are simply held accountable.

On the third day, the group is scheduled to test, adjust and retest potential solutions to see whether they make an impact. Late that Wednesday, the team members post ideas on how to change the workflow.

Kostakes says work schedules could be changed so that supply stockers come in earlier to make supplies easily accessible. Iris Meneses, the housekeeping supervisor, suggests storing supplies in a single place, cutting down walking time. Surgical assistant Paresh says the charge nurse should immediately tell the room turnover staff when a surgical procedure is complete so they can get started faster.

Then Vela makes her suggestion that patients be wheeled into the OR by technicians. The nurses push back. As the tension mounts, Barb Cwiak, the surgery manager, wanders in for a progress update.

“We don't want to offer solutions we know people won't do,” Kostakes says with a sigh. The others nod. “What are the chances they'll cooperate?”

Cwiak steps in. “You're always going to get pushback, no matter what,” she says. “But whatever this team comes up with, we'll do.” Ultimately, the Lean team decides to reassign some of the nurses' other responsibilities, such as looking for supplies, to surgical assistants and technicians to free up some of their time.

The Lean team then prioritizes the recommended changes in terms of difficulty and level of impact. Changes that are too difficult or that will have minimal impact are removed from the action list. Not every identified problem is addressed.

“You try to get improvements down to manageable chunks of things you can do,” Long says. Some issues end up in the “parking lot,” a term for difficult issues that only hospital administrators can address.

Increasing efficiency, reducing costs

On Thursday, the team goes back to the surgical floor to let everyone know the new way of doing the work. They quickly grab staff members and hand them laminated sheets detailing their new assignments.

One member of housekeeping looks relieved as she hears the news. The effort seems more comprehensive than pre-Lean attempts that addressed individual problems or singled out staff, she says.

One nurse poses so many “but what if” questions that Kostakes spends more than 10 minutes firing back “then we will” for each scenario. “Well, I hope people follow the protocol,” the nurse says before she rushes down the hall to check on her next patient. “This is a good thing.”

On Friday morning, more than 50 people, including Sts. Mary and Elizabeth Medical Center CEO Judd, chief nurse Suzanne Lambert and surgery director Kevin Hoak, fill a large conference room to hear the team's final report. Some front-line staffers who participated in previous Lean events attend out of curiosity.

The Lean team, lined up in front of separate sticky note displays, confidently present their proposed changes, which include rewritten job descriptions. They recommend assigning Lean team members to help each shift implement the new work processes. Starting Monday, there will be a daily huddle to discuss cases that do not meet the new 25-minute room turnover standard.

Lean boosters say support from top management is crucial to success of the program. Front-line staffers who perform rapid improvement experiments “love to have me come in on Fridays when we have the report-outs to hear not only their great work, but to ask for my help in the solutions,” says Presence Health CEO Bruce.

But the weeklong event is only the first step in the process. Data will be collected. Reports will be issued monthly for the next three months. Further changes will be made. Success is not guaranteed.

Long says previous Lean efforts at Presence Health hospitals have produced lasting improvements. And, perhaps more significantly, they have created a culture in those departments where employees feel empowered to send areas of concern up the ladder to leadership.

The next step for Presence, she says, is to develop a process for sharing lessons learned during Lean rapid improvement events with all hospitals in the system. Currently, each hospital holds its own events and tracks outcomes. But final results are not systematically shared.

The Lean rapid improvement process is exhausting and time-consuming. But supporters say it's one of the best ways for increasing efficiency, reducing costs, and enhancing patient and staff satisfaction.

“Show me something else that works, and I'll try that,” Long tells skeptics. “We can't just keep doing the same things and hope somehow a miracle is going to come from the sky.”

Tips From the Experts: Getting Lean

Seemingly heroic efforts could be red flags that motivated people have developed great workarounds in a broken system.  “There's enough opportunity in healthcare for necessary heroics without adding unnecessary ones. Step back and ask: ‘In this case, do they have to be a hero?’” Mark Graban, Lean Healthcare Consultant

Identify variation in which tasks are not consistently performed the same way.  “You have to know where you're starting from. If you do it one way on your shift and I do it another on mine, there is no baseline to go back and triage when something goes wrong.” Kathleen Long, Director of Breakthrough Improvement, Presence Health

Every person on staff has the ability to bring forward ideas. “Consider their thoughts the currency of the future in healthcare. We hire the smartest people in the world and then don't ask them what they think. That doesn't seem fair, or even wise.” Steve Hoeft, Senior Vice President of Operations Excellence, Baylor Scott & White Health

Don't just latch on to tools, such as the rapid breakthrough events. “That's where most organizations fail. Leadership and management needs to change the way they've done business. You can't sustain transformation without that fundamental underpinning.” John Toussaint, CEO, ThedaCare Center for Healthcare Value

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