I just finished a rather
intense, 3 ½ day improvement initiative at a medical facility and I wanted to
share what we did with everyone. If you’ve
ever had to use a hospital emergency room and one that ultimately resulted in
you being admitted to the hospital, then this blog posting might be of interest
to you. This posting is especially
relevant today because of rising healthcare costs and the impending Affordable
Care Act which will go into effect in 2014.
When we arrived at this
hospital complex a cross-functional team had been assemble and a project
charter had been assembled. The team
consisted of Subject Matter Experts (SME’s) from each of the major disciplines
throughout the hospital and as you know from my previous postings, the use of
SME’s is critical to the successful outcome of any improvement
initiatives. The SME’s represent the
driving force behind each of the individual process steps simply because they
live in it daily and are responsible for making it work. When we started this improvement initiative,
one of the first actions we accomplished was to take what we call a Team Pulse Survey (TPS) which tells us
something about the mood of the team in place.
Figure 1 is an example of a TPS.
The TPS is intended to
determine the mood of the team in terms of whether or not they believed they
would or would not be empowered to make needed changes and just how difficult
the project would be to complete. As you
can see, most of the team members believed that the project would be difficult
to accomplish and that they would not be empowered to accomplish the goal of
the project.
The problem statement for
this team was that it was taking much too long to actually admit a patient into
the hospital once the doctor determined the need to admit the patient. When we started this initiative, the average
time for the patient to actually leave the emergency department and be admitted
into a hospital ward was around 4 hours.
The general consensus of the hospital leadership was that this time
needed to be cut in half to 2 hours. I
got the sense that this team didn’t have much confidence that they could reach
this goal and the TPS results seemed to confirm this feeling.
We walked the team through
the development of a SIPOC and a Current State process map identifying all of
the steps currently in place which included things like departmental hand-offs,
communications, phone calls, faxes, etc. that exist in today’s process. This, by itself, was an eye-opener for all of
the team members. The team had no idea
that all of these actions needed to occur just to be able to admit a
patient. One of the by-products of this
exercise was that the team members gained a new appreciation and respect for
each other’s roles. The process map
confirmed that there were nearly 90 individual process stapes that made up the
current 4 hour delay in admittance.
Our next step was to color
code each step as either green (value-added), yellow
(non-value-added-but-necessary), or red (non-value-added) directly on the
current state map. We explained to the
team that if we could eliminate the “red” items, we could then reduce the
amount of waste in the process. Once we
had completed this exercise, the team receptivity level clearly improved and
they began to see that perhaps their goal could be achieved after all.
We then created an Ideal
State Map which demonstrated the ideal process or the high level actions that
make up the admitting process and then a future state process map. This future state map cemented in the team’s
mind that their goal was achievable. I
then presented a brief training session on the Theory of Constraints (TOC) and
explained that unless and until we identified the system constraint and then
exploit it, our reduction targets wouldn’t be met. The team determined that the system
constraint was the time required to clean the room before a patient could be
admitted. It was clear to everyone that
we needed to reduce this time by at least 50% if we were to achieve our overall
50% reduction in admittance time. The
team struggled with this and actually told me that it was not possible to
reduce the cleaning and prep time. I, of
course, strongly disagreed with them which turned their heads! I asked them to explain their current
procedure for cleaning and they told me that one cleaner was assigned to clean
the bed area and the bathroom. I simply
asked them why they couldn’t use two cleaners instead of one. They responded and told me that they were not
authorized to hire any additional workers.
I just laughed and explained that I found it difficult to believe that
all of their cleaning staff was busy 100% of the time and besides, the ER
patients must be the priority. There was
an epiphany that took place! They all
saw the power of using Goldratt’s 5 Focusing Steps and the problem was solved.
The point of this blog was
to demonstrate that even though TOC was initially designed to work in a
manufacturing environment, it works equally well in any environment. If there is a defined process, TOC, used in
conjunction with Lean and Six Sigma, will always result in improvement.
So what was the final
result? The original 240 minute delay
was reduced to around 70 minutes which clearly exceeded everyone’s expectations. The number of steps reduced from 90 to 40+, no
money spent, no additional manpower required, just a team of SME’s working
together to solve a problem using an integrated Lean, Six Sigma and TOC
methodology! And what about the team
pulse survey? The opinions now by nearly
everyone were that they were empowered and that the goal could be easily
achieved.
Bob Sproull
4 comments:
Hi Bob,
This looks like a regular lean six sigma project. You did use TOC but this was for a single process in a hospital. Isn't even attempting to solve this problem tantamount to going for local optima as opposed to Global Optima that TOC recommends?
In this case, it seems top management was not involved and a cross functional team was already in place just as in LSS and the lean techniques were used to optimize a local process. This may or may not have an impact on the bottom line of the hospital just like going for local optima does not necessarily help a manufacturing company.
Deb
Process improvement is so needed in Health Care.
I just experienced the wait in ER recently with a loved one and can relate to everything mentioned here. Although we are fortunate enough to meet capable,caring medical professionals; I felt it will take a paradigm shift to have them realize the possibility of improving their processes without sacrifice the quality of care provided. The "Team Pulse Survey" mentioned reflects exactly what I saw.
I am excited to see the seed is planted in Health Care industry to leverage the power of TOC and other C/I tools. Thank you Bob for sharing your experience.
Deb, yes this was somewhat of a LSS project because the goal was very clear....to reduce the wait time for admittance in the ER. However, if we hadn't focused on the constraint (i.e. cleaning the room) we would not have achieved the targeted reduction. So from this perspective we didn't focus on local optima. We did remove waste within this process, but until we reduced the constraint time by over 50% we hadn't truly improved the throughput of the ER. Thanks for your comment Deb.
Bob
Hi Sindy, thanks for your comment. I agree that there will need to be a cultural change to advance the medical profession like we need it to. This team effort is a start at least at this facility and I'm hoping they continue to make improvements. I plan to stay in touch with them and offer some free advice if needed.
B/S
Bob
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