Friday, October 29, 2010

The Culture of Lean Healthcare

We are all dedicated professionals with the safety of our patients at the forefront of our minds and yet failures continue to occur.

In my presentation, “The Human Side of Lean” the theme is about the “people,” our human side. I discuss how quality and the design of healthcare systems impact the culture and the way we do our work. It is all about the people.  Anyone who is involved in a serious adverse event is changed for the rest of their life. It alters the way they provide care and the trust they have in the system. Lean is an important part of the formula because the focus of Lean is on the people and the culture. Lean is an effective method to help people make improvements.

In a Lean culture organizations become learning environments and one of continuous improvement steered by the people

I know we are all on the same page in our efforts and devotion to provide excellence in patient care, but there are huge barriers to overcome to make that happen. Culture is the one thing that must change to make sustaining improvements. In June 2009, American Society of Quality’s (ASQ) White Paper on Health Reform supports this need for culture change. It states, “ASQ believes the most critical need of all in health reform is for meaningful, lasting changes in the deeply embedded cultures related to health and healthcare in the country.”

There are many who believe that the physicians are to blame for the culture of healthcare today, but remember they are also working in a severely flawed system. We have failed to give them a system they can trust. I believe some of the way physicians interact is due to these failed systems. Yes, they want it their way because some of the other ways do not make sense or offer the guarantee that things will happen as planned, on time with zero defects.   

It is our responsibility to make the systems work and to provide the structure and the tools to prevent the possibility of errors.  With the complexity of our systems, and the overload of information, it becomes impossible to give error free care without these changes.

Lean Healthcare strives for zero percent defects and provides the structure needed to improve patient care and support our team

We do not intentionally do harm to our patients, but it is an expected outcome. Hospital Acquired Infections (HAI)  are among the top ten leading causes death in the United States, and drive up the cost of health care by up to $20 billion per year. Research indicates that these infections strike hundreds of thousands of surgical patients and the percentage of patients acquiring these infections has steadily increased over the past six years.

In a speech by  Secretary of Health and Human Services (HSS) Kathleen Sebelius,  she discussed the 2008 National Healthcare Quality Report (NHRQ) reports on the quality of health care in America and challenged hospitals to work to reduce health care associated infections. Sebelius also called on hospitals across America to commit to reduce Central Line Associated Blood Stream Infections (CABSI) in Intensive Care Units by 75 percent over the next three years.

In the 2009 NHRQ report, they found that health care quality in America is suboptimal. The gap between best possible care and that which is routinely delivered remains substantial across the Nation. HAI’s are one of the most serious patient safety concerns. The HAI rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis.

There is no urgency in fixing this problem. The culture of patient safety is a culture of the nation, not just the healthcare organizations. With $50 million in grants given to states in 2008 to help fight healthcare-associated infections (HAI), the CABSI goal should be 100% this year.

There are JCAHO standards on the Culture of Safety, and yet organizations have changed very little on how they deal with people who are involved in adverse event. They still look at the person who made the error rather than the system. After doing many root cause analysis, it became evident to me that this person is just the last person in a totally failed process. Disciplinary action will not fix the problem and will only further prohibit the reporting of events. Even with standards in place, there continues to be errors, they do not fix these issues or change the culture.

A culture of safety is an founding principal of Lean  

Sadly, in the March/April 2010 issue of Patient Safety, there is an article providing guidelines on what to do after an adverse event. Not only are we making errors, but we do a poor job supporting our clinicians to cope with this type of event.   

Every time there is harm to a patient, it has a life changing effect on the patients, families, providers, and leadership within these organizations. I know that eventually we will improve and figure out some of the answers, but I am committed to find ways in which we can do so rapidly and effectively.

Insanity is doing the same thing over and over again and expecting different results.
Albert Einstein

“There has to be a Better Way”
Lean Healthcare is an Answer

©2010 Carol Lepper Solutions for Lean Healthcare Inc.

Monday, October 25, 2010

Patient Safety and Lean Healthcare

When I was reading the Patient Safety and Quality Healthcare magazine, March/April 2010, I was struck by how the foundation and Lean concepts are related to patient safety.  While Lean Healthcare boasts of increased efficiency, decreased costs, I have not seen the same zest or specifics about how Lean improves Quality and Patient Safety.

As a healthcare leader in patient care and safety, my experience with Lean confirms that implementation of Lean concepts will improve patient safety. The founding principles of Lean methodology are being brought forward in the literature as a venue to improve patient safety.

Lean Concepts
Continuous Improvement and Implementation of Best Practice through Standardization

Current research has proven that evidence based practice makes a difference in the quality of care. The Michigan Keystone project that focused on central line-associated blood stream infections (CLABSI) is one example. By standardizing best practice interventions, this project resulted in an estimated 1,800 lives, $281 million saved and 140,700 fewer hospital stays.

Today this program is known as CUSP, a comprehensive unit-based safety program. CUSP a collection of key changes to improve care practices related to CLABSI’s, and is implemented at the unit level.  By moving the implementation to the unit level it supports the Lean theory that establishing best practice begins with the clinicians who are performing the work. Continuous improvement strategies are performed throughout the different facilities in Michigan as each facility implements this program the results are shared and evaluated.

Lean Healthcare
Visual Workplace and Human Factor Engineering (HFE)

HFE is a science that studies how we interact with our environment and with each other and strives to optimize those interactions. It looks at ways to help us do the right thing. The writings of Donald A. Norman professor at the University of San Diego and Northwestern University, and Kim Vicente professor at University of Toronto state that there are two types of knowledge.

1)      Head knowledge, is what we contain in our human memory and is the type of knowledge that healthcare has focused on. The depth of knowledge needed and volume of information processed daily makes relying on our memory a flaw in the assumptions about our ability to provide error free care.  

2)      Knowledge of the world is the knowledge that is part of our environment. This knowledge creates mental models based on our past experiences and is used as part of our decision making process.

As healthcare becomes more complex delivering safe patient care relying solely on these types of knowledge becomes impossible. One important rule of HFE is to make things visible, which is part of the visual workplace used in Lean Healthcare. The visual use of tools gives us clues on what is the right thing to do.

Color coding is one method of using visuals. Color coding can be used in many different applications; marking different types of gas cylinders and lines, storage and labeling of lookalike sound alike medications, emergency carts supply locations and job aides on how to use the equipment, matching up IV lines to the correct medication bag. To decrease interruptions for nurses when preparing medications and performing critical tasks that could lead to errors, no interruption zones have been marked on the floors, signs are placed in the physical space, and a visual “Do not Disturb” vest has been worn by nurses. Visuals can also be used as a trigger for the next step in a process. To eliminate delays, a visual in the lab signals the staff when a specimen has been delivered and is ready for processing. All of these visuals improve patient safety.

Mistake proofing or Poke Yoke is used for system designs that prevent errors.  Some examples include the gas ratio protection in anesthesia machines, medical equipment devices that do not allow the user to assemble or use incorrectly with the design of the connections and computer fail safe software.  Another example is Broselow Pediatric Emergency Tape System which uses a visual color code that matches up the size of a child to the correct supplies needed in an emergency. When the colors are matched, only the correct supplies are available for use.

Lean Healthcare utilizes these concepts and methods that are referenced throughout this issue of Patient Safety and Quality Healthcare.  They continue to be highlighted as a practice to provide safety in our system and improve patient care quality outcomes.

 © 2010 Solutions for Lean Healthcare

Monday, October 11, 2010

Lean Thinking and Evidence Based Hospital Design

Rady Children’s Hospital to use Evidence Based Hospital Design

On October 10, 2010 Rady opened a new 4-story building which makes Rady Children’s the largest pediatric hospital in the state of California expanding its capacity from 288 to 442 licensed beds. As part of this new building Rady used a new trend called “evidence-based design.” The research results of using this design links the environment/atmosphere to better patient outcomes.  The elements of evidence-based design include such things as natural lighting, air flow, and room design – private rooms with space for family members to stay with loved ones, soothing atmosphere, and use of sound with waterfalls, aesthetics like artwork and the use of color.

Many hospitals are beginning to expand, and they are using evidence-based design.  As I thought about these new methods of construction, I had concerns about the use of space and what it does from an efficiency perspective. Does evidence-based design address the physical work flow inefficiencies in our current system? These designs include input from patients and families, but how much are users consulted? Historically new plans fail to consult the users of the system, resulting in an increased waste of time with movement in the new design.

As I was doing Lean consulting at other hospitals, I found some examples of new construction that did not include input from users.  In the entrance of a new building there was a long beautiful atrium, with patient care services housed along all sides of this atrium. When I first observed this space, I thought this is going to be a long walk for nursing to deliver care, it was about a quarter of a mile one way. There were Pod designs where the nurse could only see only a small section of patients and had to walk around the whole pod to get to the nursing station. Another nursing station had only one way in and out creating congestion, confusion and increased walk.  Ancillary departments were not moved along with the new space increasing the walk and turnaround time for service. 

A hallmark of Lean Thinking in healthcare is to remove waste which will increase efficiency, improve quality and decrease cost. Lean includes the front line workers in all process improvements, including new construction. The implementation of Lean Healthcare prior to new building improves the physical design and efficiency.

The costs of these new buildings is increasing, so can we consider smaller square footage for new buildings?   In the past, implementation of Lean has lead to cost avoidance by decreasing the size of new projects. This is due to the fact that as Lean improves the turnaround times for care, it increases capacity without adding beds.    

After the Rady hospital opens it will be interesting to see how the design impacts patient flow and the movement of staff.  As research continues to evaluate the use of evidence- based design, efficiency must be one of the measures included.