Ben Geboe
Description of Lean Activities
Lean uses tools from the Toyota Production System to improve hospital operations. The challenge of introducing a new improvement methodology requires engendering support from high level directors, department heads, as well as from the people doing the work. I have successfully conducted 60+ Rapid Improvement Events to improve hospital operations. I have included a few concrete examples for review in detail and a listing of all events to date.
Problem:
The Adult Emergency Department (AED) and Outpatient Practice Department (OPD) referral process was not coordinated. The Emergency Room Doctors routinely referred everyone they saw to OPD clinics, half of whom did not show up and clogged access for the public or inpatients. Many times patients would just show up saying they were told verbally to come to the clinic.
Solution:
A joint authored AED and OPD referral guideline was created that informed all staff how to make an appointment; during business hours and after hours and weekends. A short list of conditions rarely needing follow up was created in the AED by Doctors to identify patients who would not need a follow up in the OPD (sprained ankle, conjunctivitis, etc.) The AED staff directed patients to their own Doctors for follow up when appropriate. These countermeasures helped reduce the amount of patients incorrectly referred and reduced overbooking of the clinic schedule.
Problem:
On time start of the Operating Room (OR) was impacted by Perioperative Services staff Nurses who had to gather supplies needed for surgical cases every morning. Anesthesia would cancel surgery for clinical reasons on the day of surgery when the patient was ready and waiting in the holding area. This negatively impacted on time start and utilization of the OR.
Solution:
The OR night shift were trained to help pick supplies needed for the next day case, so that day time Nurses would have everything they needed to start the surgery on time. To prevent delays and cancellations the Anesthesia department changed their preoperative consult to the day prior for inpatients and a week ahead of the surgery for outpatients. Cancellations for clinical reasons could be filled with the next available case because staff, Surgeons and the patient were provided with advance notification.
Problem:
Patient demographic and clinical information was not being routinely updated by Clerical Associates in the electronic medical record causing the potential to misidentify patients in the clinics and creating difficulty notifying them after their appointments. Doctors and Residents would not fully describe the patients medical history and only documented the current issues that related to their specialty (e.g. ophthalmologists would not routinely document chronic conditions.)
Solution:
All staff were provided with education and training on what to update and how to record the information accurately. Information and Technology (IT) changed the layout of some of the most important computer screens so staff could update them quicker and with fewer steps. Staff were given uniform access to electronic health records and managers were provided with auditing tools to support and monitor sustained documentation. Doctors were provided with a comprehensive listing of chronic medical conditions and provided with education and training on how to use IT improvements to fully describe the patient health status.
Problem:
Cancer inpatients needing radiation therapy were routinely transferred off site to receive therapy daily because the hospital did not provide radiation therapy. Intravenous medications would be unhooked and hooked back up again daily during transport and the patient was already very ill. The transportation and treatment took four hours. This impacted patient ability to remain ambulatory and atrophy would cause them to stay inpatient for longer periods of time.
Solution:
Oncology Providers created clinical guidelines that directed staff to arrange outpatient radiation therapy when appropriate. This provided for the early discharge of patients to their homes, and helped them remain ambulatory longer. The patient discomfort was minimized and transportation costs were avoided.
Problem:
Nurses had to do a substantial amount of walking to provide patient care on inpatient units. Assigned patients were located all over the unit and each Nurse and Nurse Assistant would work independently to deliver care. Nurses would lose valuable time fixing ancillary problems (housekeeping room change over, picking up medications from pharmacy, dropping off lab specimens, etc.)
Solution:
Nurse assignment included patients located adjacent to each other to minimize walking, and Nurse Assistants were assigned to the same Nurse and patient to promote team delivery of care. Ancillary services were engaged to minimize Nursing having to change linens, leave the unit to get medications or, deliver specimens by coordinating extra help or additional pick up times when needed.
Problem:
Medical Records had to sort, file and archive over one million paper documents related to patient care every year. Hospital staff did not know what to send to Medical Records or what to discard, so staff sent every piece of paper generated in the hospital.
Solution:
Medical Records created a guideline to direct staff what to send and what to discard. Printed out copies of information already in the electronic medical record were deemed unnecessary. Radiology reports needing storage were identified to be printed out and sent for archiving (the X-Ray machine holds only the most recent 100 tests and deletes previous records to make room for new tests.) Departments and services not online yet were identified for training and education to use the electronic medical record. Lower volume allowed Clerical Associates to be redeployed to clinics to help with patient registration.
The Transformational Plan of Care (TPOC) entails senior executive leadership defining areas needing improvement in the hospital during a 2 day event. These areas are called Value Streams and are reviewed by directors and managers from the area in a Value Stream Analysis (VSA) held during 2.5 days. The VSA plans Rapid Improvement Events (RIE), each lasting 5 days, to improve an area and align metrics from the discrete area with the VSA and TPOC metrics.
Listing of all Lean TPOC and VSA Events to date:
Rapid Improvement Events (RIE) are the main tool for creating change to identify and remove waste and make the operational process better. Each RIE focuses on an incremental unit or operational function in a Value Stream. Several RIE are done in each Value Stream to improve the overall flow, however each RIE only focuses on an incremental part of the process.
Rapid Improvement Events: