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Emergency Medicine Physician Responds to Recent Article About Lean Success

Posted on Thu, Oct 29, 2015
Emergency Medicine Physician Responds to Recent Article About Lean Success

A recent article in FierceHealthcare highlighted the successes that Stanford Hospital and Clinics have seen after implementing lean manufacturing principles. However, one of EmCare’s advocates for lean cautions the system, stressing that administrators shouldn’t ease up on the gas pedal just yet.

The health system has seen ED wait times drop by 17 percent despite an increase in patient volume and flat operating costs, according to the article.

“The initial gains such as the ones cited in the article are great, and I wish Stanford continued success in its lean journey.  I just hope the journey doesn't end prematurely when the political waters run deep,” said Joseph Twanmoh MD, MBA, FACEP, FAAEM, Director for Health Systems Innovation for EmCare’s North Division.

Because there is so much waste and inefficiency in healthcare, lean has great potential to improve service delivery, explained Dr. Twanmoh.  The challenge is deploying lean properly and making sustained gains.

“Too often lean is used as the latest tool or fad to cut costs or improve efficiency, without senior leadership being truly committed to the principles of the Toyota Production System. Initial gains tend to be easier, as there is plenty of low-hanging fruit. As one climbs the mountain of waste that exists in healthcare, the problems become harder to solve,” said Dr. Twanmoh.

He explained that as a facility moves forward on its lean initiative, it starts to deal with more entrenched behaviors that require more political capital to solve. For instance, ED boarding and patient flow may be related to OR scheduling, the rounding practices of physicians on the inpatient services, the staffing patterns of nursing, or the availability of housekeeping on second and third shift.

“Will senior management be willing to support lean efforts and change processes to create value from the perspective of the patient? If a system is truly committed to lean, then things such as changing block surgical scheduling, setting standards as to when patients are evaluated on inpatient units, and how nursing units are staffed are all fair game for change – and those aren’t quick fixes,” said Dr. Twanmoh.



Joseph Twanmoh MD, MBA, FACEP, FAAEM, is Director for Health Systems Innovation for EmCare’s North Division and the Senior Vice President of the MS2 Group, Providence, R.I. He is a Lean-certified physician with expertise in change management. Dr. Twanmoh has more than 20 years of leadership and management experience turning around emergency departments, redesigning hospital processes, and improving patient flow. Dr. Twanmoh previously served as a Medical Director and ED Chairman. He is a graduate of Rutgers-Robert Wood Johnson Medical School and received his MBA from the Johns Hopkins University Carey Business School. He is past-president of the Maryland chapter of the American College of Emergency Physicians, serves on the Practice Committee for the American College of Emergency Physicians, and is a fellow of the American College of Emergency Physicians and the American Academy of Emergency Medicine.
 

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Why Lean Fails: The Challenge of Variability

Posted on Tue, Sep 22, 2015
Why Lean Fails: The Challenge of Variability

Part Two of a two-part series.
 
By Joseph Twanmoh MD, MBA, FACEP, FAAEM

In Part 1 of this two-part series, we discussed the history of the lean process improvement methodology, its basic tenets and how lack of leadership commitment can doom a hospital’s efforts to achieve efficiencies with lean projects. This post explores the differences between manufacturing and healthcare, and how these differences can adversely affect lean projects without mitigation.

Leadership commitment is crucial to reaping the rewards of lean. Teams need the appropriate support to plan and execute lean projects. Time is required to meet, collect data, test ideas and make any necessary changes prior to implementation. This is the classic Plan-Do-Check-Act Cycle of process improvement. When leadership doesn’t understand lean, they believe that they can just add on these additional responsibilities to managers and front line staff; dedicated time and resources for the lean improvement process isn’t viewed as a priority.

When lean is used as a tool only, piecemeal implementation can occur. Hospitals may do a rolling start, where lean is introduced in one department at a time instead of house-wide. This leads to communication failures between the departments and hampers lean implementation. An example is when the emergency department begins using lean, but the registration department does not. The ED team re-engineers their patient intake process and later informs Registration of some changes that are planned. The ED Lean team explains to Registration that the new process will revolve around the needs of the patient, add value to the patient, and reduce waste and non-value-added activities. Registration’s response is that the old process is fine because “this is the way we’ve always done it.”
 
Another phenomenon that occurs when lean is simply used as a tool is discontinuous improvement. Lean is all about continuous improvement. The quest for quality is never finished, with teams constantly moving from one project to the next. What happens all too often in healthcare is the “one and done” mentality. The team works on the particular project, finishes that project, and then considers their job finished. They never monitor the effectiveness or go back for a second or third round of improvement. The result is initial gain followed by backsliding, so the conclusion is that lean doesn’t work.
 
Choosing the Right Lean Project
 
Internal lean teams often work without the help of expert guidance. The result is that teams can pick the wrong project. If they pick projects that are too small, it results in meaningless outcomes.
 
For instance, an emergency department could have very long patient lengths of stay and one aspect of that problem could be the turnaround time for CT scans with contrast. However, if a team chooses to work at reducing CT turnaround time with a goal of reducing overall length of stay, it’s unlikely that its work will have any meaningful impact, because CT turnaround represents only a portion of the patient’s length of stay, and the number of patients receiving CT scans with contrast represents an even smaller percentage of the total number patients in an emergency department. Consequently, any time savings on CT turnaround is diluted when calculating overall length of stay. If a team chooses a project that is too large, such as reducing the length of stay for both discharged and admitted patients in the emergency department by 50 percent in the next six months, then the number of processes and workflows to be re-engineered becomes overwhelming and the team fails.

The Challenge of Variability: Manufacturing and Medicine Are Not the Same
 
Lean has a number of inherent shortcomings when applied to healthcare. First, lean delivers incremental change. As a result of incremental change, it can take a long time to get the desired outcome.
 
For instance, shortening ED length of stay is a very complex process. There are hundreds of steps in different processes that happen from the time a patient arrives until the time of discharge or admission. Taking on this project from a lean perspective requires breaking down the patient’s ED visit into small, manageable pieces. Therefore, it would take a series of lean projects to make a meaningful impact on length of stay. Particularly when leaders are not fully committed to the lean process, this incremental change is perceived to take too long, and therefore efforts often are abandoned.

Lean may be helpful to get one from Point A to Point B more efficiently. However, lean may not be helpful in telling you where Point B is. In most hospitals, the staff of nurses and physicians may have only worked in one or two other institutions. Consequently, if you’ve never worked in or been exposed to a highly efficient system, how would you know how to design one? If you take a group of people who are not experienced bakers and give them a recipe for an apple pie, what’s the likelihood that they will produce a world-class apple pie? Probably fairly low. Yet we put together teams of healthcare professionals who may never have worked in an operationally excellent facility and expect them to come up with a world-class process design using lean. Without appropriate expert guidance, their likelihood of success is fairly low.

In addition, there is variability in healthcare that lean has trouble addressing. Toyota believes that the right people following the correct processes will result in desired product. This is not the case in healthcare. Not all patients with pneumonia will respond to antibiotics, even when appropriately chosen and administered in a timely fashion. Not all patients with heart attacks survive even when life-saving cardiac catheterization is available in 90 minutes or less.
 
In manufacturing, one source of variability is materials. Toyota works hard to reduce the variability of materials. It works closely with suppliers to ensure that parts are free of defects. However in healthcare, our materials are our patients, and patients are rarely alike. Age alone is a major variable. Caring for a newborn is much different than caring for a 5 year old. Caring for a 20 year old is much different than taking care of an 80 year old. A morbidly obese, hypertensive, diabetic 50-year-old male with an ankle fracture is a much more challenging patient to care for than a healthy one.
 
The other main sources of variability in manufacturing include man, methods and machine. Man represents the workers. At Toyota, its workers are the associates on the assembly line. In healthcare, man represents physicians, nurses, technicians and the rest of the staff who directly impact the patient. Physicians and nurses have independent licenses to practice, and their licensing boards hold them to standards above and beyond that of their jobs. Consequently, changes involving patient care are much more difficult to implement than changes around the assembly line. Furthermore, not all doctors and nurses have the same background and training although they may hold the same degrees. As a result, there is variability around the healthcare worker that is more difficult to address than that of a manufacturing worker.

Then there are methods. Toyota tries to standardize methods as much as possible. And while there is certainly room to improve standardization in healthcare, there is much variability that is hard to overcome. Not all orthopedic surgeons perform joint replacement surgery using the same technique or same prosthesis. Take weight loss. What is the best diet? What type of exercise and how much should one do? Should dietary supplements be used? When should bariatric surgery be used? The evidence is not always clear.

Regarding machine, Toyota believes that all equipment should be in good working order and standardized wherever possible. However, in most hospitals, equipment is replaced over time. As an example, it’s not uncommon for hospitals to have multiple types of stretchers. Sometimes the stretchers are from different manufacturers. Sometimes they’re simply different models from the same manufacturer. Nevertheless, controls and functions may differ. For instance, some have scales built in and others don’t. The standard workflow for weighing patients may vary depending on the stretcher used.
 
Lastly, lean attempts to produce “single piece flow” whenever possible. Batch processing is considered bad and should be avoided. However, in the emergency department, patients rarely arrive in an orderly manner. Frequently, they show up for triage in groups of five or 10 or maybe 20. And while this flow of patients is considered natural and may be predictable, the predictability is not always precise.
 
For instance, Mondays always tend to be busy days, but can you predict with certainty how many patients will arrive two weeks from now at 10 a.m.? We know that volumes rise during flu season, but the severity of the flu in a given season is never known in advance. Lean doesn’t provide the tools to deal with this variability.
 


Joseph Twanmoh MD, MBA, FACEP, FAAEM, is the Senior Vice President of the Mid-Atlantic Division of MS2, Providence, R.I. He is a Lean-certified physician with expertise in change management. Dr. Twanmoh has more than 20 years of leadership and management experience turning around emergency departments, redesigning hospital processes, and improving patient flow. Dr. Twanmoh previously served as a Medical Director, ED Chairman and Director for Health Systems Innovation for EmCare’s North Division. He is a graduate of Robert Wood Johnson Medical School and received his MBA from the Johns Hopkins University Carey School of Business. He is past president of the Maryland chapter of the American College of Emergency Physicians, serves on the Practice Committee for the American College of Emergency Physicians, and is a fellow of the American College of Emergency Physicians and the American Academy of Emergency Medicine.

 

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Why Lean Fails: Commitment Is Key

Posted on Tue, Aug 11, 2015
Why Lean Fails: Commitment Is Key

This is Part 1 of a two-part series about the challenges implementing Lean processes.

By Joseph Twanmoh MD, MBA, FACEP, FAAEM

Virginia Mason Hospital and Medical Center in Seattle is the poster child for Lean in healthcare. Consisting of a 336-bed hospital, multiple clinics and multispecialty group practice, Virginia Mason was named Leapfrog Group’s top hospital of the decade. But it wasn’t always that way.

In 1998, Virginia Mason was losing money. In 2000, its board of directors decided that change was needed, and a new CEO was hired. Coincidentally, Boeing, also based in Seattle was 7 to 8 years into deploying the Toyota Production System, the foundation of Lean process improvement methodology. In 2002, Virginia Mason began its Lean journey. The hospital’s leaders took their first trip to Japan to study from Toyota and they return every year for two-week intensive study missions.

The hospital’s success stories include:
 

  • ED Redesign: Like many emergency departments, Virginia Mason’s was frequently closed to ambulances. Using Lean, low-acuity patients were identified and quickly discharged, saving beds for those more acutely ill. As a result, ambulance diversion was decreased by 90 percent.
 
  • The Patient Safety Alert (PSA) system: The PSA system requires all staff to immediately report any threats to patient safety and stop any activity that could cause further harm. Investigations are immediately launched to correct the problem. Prior to the PSA system, safety complaints took months to be resolved. Between 2002 and 2009, more than 14,000 safety alerts were reported. Now, most safety concerns are processed in 24 hours. Patient safety has improved and professional liability claims have dropped.
 
  • Cancer Center Redesign: Previously, oncology patients traveled throughout the hospital for chemotherapy. Now, treatment is brought directly to the patient in his or her private room. For the patient, a 10-hour visit has been reduced to two hours.
 
  • Nursing Workflow Redesign: In many hospitals, nurses spend about 65 percent of their time in non-direct patient care. Using Lean, nurses and techs work as teams geographically located near their patients. Supplies were reorganized to be closer to the patients and care teams. Virginia Mason’s nursing teams now spend 90 percent of their time on direct patient care, instead of just 35 percent as before.
 
  • Hyperbaric Medicine Redesign: When the Center for Hyperbaric Medicine appeared to outgrow its existing space, the original solution was a new building with larger chambers. Lean teams were able to design and build a new hyperbaric center in existing hospital space, saving $2 million in construction costs.

Have you been using Lean at your hospital but not getting these types of results? You’ve read about Lean and maybe even taken a Lean certification course. Why has Virginia Mason been so successful with Lean where others have not? While the questions seem straightforward, the answers are not. The short answers revolve around Lean implementation, differences between manufacturing and healthcare, and inherent Lean limitations.

Lean: The Early Years

Lean is a term used to describe the Toyota Production System. From the ashes of post-World War II Japan, where Japanese industry was literally in rubble, Toyota rose from a seemingly insignificant motorcar company to one of the world’s most profitable and respected auto manufacturers. Toyota sent engineers to the United States to study the automotive industry. One of those engineers was Taiichi Ohno, considered the father of the Toyota Production System. He realized that Japan could not possibly compete with the US using the same American methods of mass production. Obsessed with waste, he instead challenged his engineers to develop more efficient systems. Thus, the Toyota Production System was born.

The Toyota Production System is based on the Toyota Way, consisting of the Four Ps and 14 Principles.

The four Ps are:
  • Philosophy
  • Process
  • People and Partners
  • Problem Solving

Toyota’s philosophy is to add value to their customers, society, community and associates. Toyota strongly believes in process; that the right process will yield the right results. Conversely, you can’t get the correct results with the wrong process. Toyota believes in investing in people and partners. The company believes that it has an obligation to develop and grow both its associates and partners, such as suppliers and key business relationships. Lastly, Toyota believes in problem solving – that improvement should be continuous and that the pursuit of quality is never ending.

Toyota places these four Ps and 14 principles into a pyramid, which is symbolic. The base of the pyramid is Philosophy, the next layer is Process, followed by People and Partners, with the top being problem solving. Toyota believes that you cannot operate at the top of the pyramid without having a solid foundation and base.

Lean Pyramid
Image courtesy of Toyota Production System

Not Leaping for Lean?

This graphic reveals the first reason Lean so often fails in healthcare. When Lean was implemented at your hospital, how much time was spent on philosophy? Did everyone in the institution understand that it’s necessary to place the needs of the customer – the patient and his family – first in designing processes? Did you show respect for direct caregivers by creating work environments that are safe and rewarding?

Toyota has a phrase: Treat each line worker as a surgeon. The line worker has the most important job, directly making the product. Their work environments should be clean, well-organized, and safe to minimize errors and maximize efficiency. Is that the situation at your hospital? Are your rooms adequately stocked? Is equipment readily available and in good working condition? Is your computer system user friendly to minimize wasted time and errors? Did your senior leadership go to Japan to study at Toyota? Likely, the answer to these questions are no.

The first failure with Lean in healthcare is a lack of leadership commitment. Too often it’s viewed and used simply as a tool to cut costs or solve a problem. Remember, Toyota believes that you cannot operate at the top of the pyramid (problem solve) without a secure foundation (philosophy and process).

When leaders are not fully committed to the mission, it’s a signal to the rank-and-file. People simply will not follow when leaders aren’t committed. Imagine a general who isn’t committed to his mission. Do you think the troops will give 100 percent effort? When leaders pay lip service to Lean, it becomes readily apparent.

Dr. Twanmoh is the Director of Health Systems Innovation for EmCare's North Division and the Senior Vice President for the MS2 Group, a healthcare consulting firm that specializes in patient flow optimization and readmission reduction, creating sustainable solutions for hospital clients. With more than 20 years of experience as a medical director and board-certified emergency physician, Dr. Twanmoh understands both strategy and operations, keeping the big picture in mind when re-engineering patient flow. Certified in Lean and with expertise in change management, he has applied those techniques to seek innovative solutions to improve patient outcomes and service delivery.   Having worked for an independent physician-owned emergency medicine practice, contract management groups, and as faculty in an academic institution, Dr. Twanmoh has a deep understanding of the challenges and opportunities facing physicians in each of those employment arrangements. A graduate of Rutgers-Robert Wood Johnson Medical School, he received his MBA at the Johns Hopkins University Carey Business School. Dr. Twanmoh is a Fellow in both the American Academy of Emergency Medicine and American College of Emergency Physicians.  He is a past-president of the Maryland Chapter of the American College of Emergency Physicians and serves on the Emergency Medicine Practice Committee for the American College of Emergency Physicians and is the co-chair of the Operations Management Committee for the American Academy of Emergency Medicine.

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