Friday, September 14, 2012

Focus and Leverage Part 140

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.

Figure 1

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


Anonymous said...

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.


Sindy Su Chu said...

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.

Bob Sproull said...

Deb, yes this was somewhat of a LSS project because the goal was very 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 Sproull said...

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.