Editor’s note: This case study began in December 2015 after a paper was published in Administrative Science Quarterly entitled, “Polish dialysis center employees use visual management to increase safety, improve organization of medical facility,” by Złotowska et al. Enabled by collaboration software and assisted by online language translation, and combined with Ms. Złotowska’s bilingual skill, we were able to apply a framework to the completed Lean-basis project that shows a health care quality return on investment (a methodology known to commercial firms over the past 30 years as “cost of quality.”)
This is part 1 of the series. Part 2 covers activities and costs relating to the investments, monitoring, and waste.
The Regional Center of Nephrology (RCN) is a small organization specializing in the care of patients with chronic kidney disease. RCN has facilities in Miastko and Szczecinek, Poland. Our view of the mission begins with the patient: We believe it is important to visit a qualified specialist in the shortest possible waiting time. Few patients are aware that all medical services are processes consisting of clear steps, and there are many variables that affect wait time and quality of care. In addition, there are many processes where one begins at the end of another process in a complementary fashion.
An engineer visiting a doctor sees the work differently, and will ask:
- How long is the wait for a suitable office
- Will it be on time?
- What are the indicators of quality care?
- How are expectations seen and addressed?
- How smoothly do patient schedules flow?
- Are messages consistent?
- Is signage appropriate to the process.
The primary issue is how to arrange and implement activities in an optimal way for patients, physicians, and staff. Thinking more broadly:
- How can we design space that will be flexible and useful well into the future?
- How can we do more with less?
- How can we design a useful space adaptable to the needs of all participants in the process?
The RCN has maintained quality systems for several years. It started with ISO 9001 and later applied the standard BS EN 15224. When implementing this standard, RCN noted the need for tools that not only systematize the work, but also improve processes and standardize risk management.
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In industry, a primary discipline formed to answer these questions is Lean. Since Lean focuses on human work, there is no reason that Lean would not help in a health care setting.
In 2013 and 2014, RCN began implementing Lean principles. When observing daily processes and events, RCN managers noticed that work was not always easy and safe. Our patients and employees found problems with certain places not being as accessible as they could be.
In Lean, visual management (VM) is the tool to address these issues. None of the employees at RCN had heard of VM, but they have used it unconsciously. VM is a technique of communication that distributes messages and situational status directly and indirectly to employees involved in the process. With VM, everyone can quickly assess the status, which in turn allows quick capture and correction of deviations. VM allows you to get the job done faster and in accordance with standard work steps. A review of some common situations at RCN confirmed that visual management could help some issues. VM answers the question: “How can we design the common space, in order to be most usable and best adapted for the current needs of process participants?” In addition, VM makes work standards more transparent.
Identify the problem
Some processes used in the RCN were not optimally managed. Because patient safety is a primary concern, RCN had to increase safety. Some workspaces were disordered, some job functions were arranged in less than ideal ways, and many resources were left uncounted and forgotten. Workplace organization did not serve to add value (what patients would see as value), because waste was occurring.
Despite the implementation of health sector standards, the organization still experienced delays in preparing work. Medical equipment was frequently moved from place to place, causing both equipment damage and extra effort to locate and check the equipment when it was needed. A particular issue concerned medical equipment such as ultrasound, EKGs, and patient scales that were often damaged. This made more effort for medical personnel both in looking for equipment and increased the risk of equipment not conforming to technical specifications.
The list of problems included:
- Wheelchairs stored in traffic routes
- Medical equipment without permanent locations
- Mixed sitting and standing areas
- Exploratory equipment and materials located in inconvenient places
- Cleaning materials were not located where they would be expected
- Inventories contained expired medications, and the inventories of medicines, disposable materials, and medical equipment were too high
These inventory problems created fatigue for orderlies, who had to search the warehouses for items and also perform an additional count of inventory in the warehouse, an ad-hoc and poorly controlled process. Within the RCN, there were problems in common areas at the hall of dialysis (a branch of the diabetic and nephrology clinics.) All of these difficulties caused additional frustration of staff and reduced the quality level of the work.
Barriers and issues were identified in April 2014, but this situation has been occurring since 2013. These problems concerned all the medical personnel in the RCN: nurses, physicians, ward nurses, cleaning staff, management staff, and patients. Both clinic locations in Miastko and Szczecinek were included, and both medical units showed largely the same situation. Some affected employees were process owners, some were practitioners, and some were facilitators.
The following list offers an understanding of the size of the affected population:
- 52 employees
- 64 patients on dialysis
- 300 hospitalized patients
- 1,200 patients using the clinic in one year
There was resistance to the changes, so the clinic personnel were organized into teams and performed the brainstorming themselves. Everyone prefers to be a part of change, and not have change ‘done’ to them.
The chart in Figure 1 shows the RCN key performance indicators before and after visual management tools were implemented. Thanks to Kanban cards (which create flow in warehouses) and improved product identification and retention, safety stock was held at an optimum level. This helped reduce the quantity of drugs and medical equipment by about 30% yearly. This saved more money, which allowed a better time-value-of-money (increased investment value or reduced borrowing expense). Replacing the old plan with the newer FEFO method (first-expired, first-out) inventory scheme was better because there was a significant reduction in the quantity of expired drugs discarded.
Using flowcharts for core processes, many actions were eliminated that were useless or repeated without adding value. This helped us to shorten takt time. Takt time is an indicator which shows us how often one customer order should be realized according to time on the shift; it is calculated as available production time divided by customer demand.
These changes reduced the time for patient treatment processes, standardized work processes and smoothed the information flow. Brief and readable diagrams encouraged medical staff to use a process map, improving safety at the same time. After flowchart implementation, overprocessing was reduced by about 50%. Overprocessing comes from unstable clinical processes created by different physician’s work practices. Waste reduction for unstable clinical processes could be realized several ways; these will take a longer time for the process improvement teams to remove waste and add value.
After storage areas were identified and marked, the volume of equipment damage was reduced by about 50%. Better storage of equipment helped to achieve better continuity of processes. Cleaning costs fell by about 40% due to separate laundry rooms on each floor, and dedicated cleaning tools and materials.
Failure Modes and Effects Analysis (FMEA) was applied to clinical risks (see Table 1). In the sample shown, the RCN is seen (a priority number from FMEA) for the hemodialysis process and treatments in the nephrology ward. The biggest improvement was for patient infections. All of the actions shown in Table 1 were addressed. The right hand column shows the degree of improvement in RPN or priority scores produced by the action plans.
Our journey using lean principles started at a good time; it wasn’t too late to implement improvements and we became more conscious about quality and patient safety. In Part 2, coming next month in NN&I, we will share the results of our efforts.
Startup personnel and the first steps
The first step was to analyze the current state of equipment and facilities. Medical devices were rated according to whether they were located in areas where they were used or moved over long distances. In all major work areas, the teams checked the availability of required materials and equipment. Solutions began with locating medical equipment in fixed areas convenient for use. Floor markings were used to make sure staff replaced equipment in the proper locations.
Can Lean work in health care?
Can a technique such as Lean that was developed for car manufacturing be adapted for hospitals? Consider that in both cases there are work processes that use operating resources that interact to create added value. In both cases there is a “medication” that can increase added value and reduce waste and non-value added time along with expenses. The philosophy of lean management using the appropriate methods to eliminate unnecessary activities and losses (time, money, resources) will also increase the quality, safety and efficiency of processes. Lean takes note of quality indicators, patient and employee expectations, and patient flows in processes. Lean uses clearer communication with an appropriate system of information signaling and creates overall smoother process flow.
Is it possible to better manage clinical processes to minimize risk and also save money? The RCN invested in time and the work of several people; this resulted not only in better management and improved patient satisfaction, but in an outstanding return on investment. A savings is not the critical driver, but it is a way to compare the improvement efforts to budget planning and possible financial outlays.
While realizing the kaizen way and move from waste to value added, there is an important element that shouldn’t be missed: communication. It’s a generally known aspect of management but with a big influence on this project.
In the beginning of the project the medical team was not open and sympathetic to new methodologies and changes. It may have been because of a strange and unknown vocabulary (5S, 5why, VM, VSM, PFD or process flow diagram). The RCN engineer noticed this at the very beginning and chose new and easier terminology for “users” creating a user-friendly environment. When talking about Lean tools and training, every instrument has a new name, because of the new purposes. For example: not calling it ‘5S,’ but instead ‘clean and orderly workplace,’ not ‘flowchart’ but ‘way of doing the treatment process.’ This was a better way and it has encouraged participants to do more activity and share their own ideas and comments.
In part 2, activities and costs relating to the investments, monitoring, and waste will be covered. Part 2 will conclude with the overall return on investment and results of the project.
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- Locher D. Lean w biurze i usługach, tłum. [Lean in the office and services, trans.] Gasper D., MT Biznes, Warszawa 2012
- Wruk-Zlotowska A., Komunikacja pomiędzy pacjentem a pielęgniarką jako element bezpieczeństwa procesów klinicznych.[Communication between patient and nurse as element of safety clinical processes], Medical Maest