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 Zlotowska et al. Enabled by collaboration software and assisted by online language translation, and combined with Ms. Zlotowska’s bilingual skill, the authors were able to apply a framework to a Lean-basis project at the Regional Center of Nephrology, located in two towns in Poland, that showed a health care quality return on investment.
Part 1 of this article was published in the March 2017 issue of NN&I. This is the second and final part.
Can a technique such as Lean that was developed for car manufacturing be adapted for hospitals? Consider 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. It 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 Regional Center of Nephrology 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. Savings is not the critical driver, but it is a way to compare the improvement efforts to budget planning and possible financial outlays.
Communication is integral
While realizing the Kaizen way and moving from waste to value-added medicine, there is an important element that shouldn’t be missed: communication. It is a generally known aspect of management but with a big influence on this project. In the beginning, the medical team was not open to new methodologies and changes. It may have been because of a strange and unknown vocabulary, or new tools like a process flow diagram. The Regional Center of Nephrology engineer noticed this at the very beginning and chose new and easier terminology for “users” in an effort to create 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. (5S involves the following steps: Sort out and separate that which is needed and not needed in the area; Straighten: Arrange items that are needed so that they are ready and easy to use. Clearly identify locations for all items so that anyone can find them and return them once the task is completed. Shine: Clean the workplace and equipment on a regular basis in order to maintain standards and identify defects; Standardize: Revisit the first three of the 5S on a frequent basis and confirm the condition of the Gemba (defined by the Japanese as the “real place”) using standard procedures. Sustain: Keep to the rules to maintain the standard and continue to improve every day.)
Significant time investment began with the next step: holding meetings with staff (nurses, doctors, orderlies, and support engineers). The support engineers provided Lean tools for the staff to use. The tools were presented with practical examples from other health care settings.
After these meetings and presentations, the team went into brainstorming mode, which was an important step in the creation of an implementation plan for visual management tools. The team collected ideas that concerned the areas and aspects for improvement to use as a guide for applying the tools and methods of lean management. The work was quick and enthusiastic, and it fired up the creativity of staff to the extent that they wanted to apply tools in their daily work at RCN.
It was decided to apply:
- the 5S method
- flowcharting for the clinic core processes. These tools resulted in better:
- visualization of equipment
- material holding areas organization
- quality documentation
- use of color for signs and marking
The teams applied different colors of uniforms for medical personnel and color standardization of equipment for cleaning. They also developed process flowchart diagrams for the seven main processes at the RCN:
- Peritoneal dialysis
- Advice for nephrology
- Advice for diabetes
- Hospitalization in a nephrology ward
- Treatment of anemia in predialysis
- Treatment of hyperparathyroidism in patient’s hemodialysis
Planning is central to repeatability of service delivery, better process stability and maintaining the desired level of service quality under a Lean process. We designed ‘road surface’ markings on the floor for intermediate storage space for medical equipment (beds, wheelchairs, chairs, scales, ultrasound, ECG, cleaning equipment, tables, hand sanitizer). The center purchased yellow signs for wet floors. They also purchased red and yellow tape to separate equipment and materials holding areas and outlined the best safety stock levels in the warehouses. Standard colors were established for the various staff. Kanban cards to control inventory and reordering were implemented.
The one-time investment to initiate and execute visual management at the Regional Center of Nephrology in Poland involved:
- Analysis of equipment, assets, and storage use
- Staff meetings on Lean methods and brainstorming
- Designing and printing equipment and floor markers
- Flow charts of key processes
- Floor signs and tape
- Document organization
After implementing changes, monitoring is needed to ensure the changes do not slip away. The staff were aware that Lean philosophy does not rely on a single solution implementation, but on continuous improvement.
Orderlies at the end of each shift do the monitoring. They evaluate the 5S status in the facilities and infrastructure in the RCN each day. The assessment uses a customized evaluation sheet for 5S. Orderlies evaluate not only the adherence to procedures, but also the general condition of the infrastructure and results of their work. It takes an average of 10 minutes per day so they can do it while completing their regular tasks.
Every week an engineer updates a visual array of qualitative indicators. This data is presented in a clear, understandable way and is accessible to all staff. This allows for quick assessment of the organization. As a check on the daily assessment, 5S audits are conducted by the engineer and presented to those responsible for area processes. This audit helps the assessment to gather and focus the topics to be discussed and resolved. The work of the orderlies is guided by the saying from Henry Ford: “Quality means doing things right when no one is watching.”
The monitoring results in changes each quarter. The streamlining of processes is analyzed by all, and presented at the team quality meetings.
Waste in Lean is sometimes called muda (from Japanese). Muda comes from all activities and operations that do not add value to the process. The costs of these wastes are often not calculated, but the reduction of these wastes is what allows a return on investment. The waste lengthens the process and in doing so adds costs that the patient and the payer or the National Health Fund would not pay. These were the most easily identifiable wastes at RCN:
Unnecessary movement of nurses. During hemodialysis treatment, ward nurses often have to look for materials needed to perform the work. The teams looked at waste not only in the hall of dialysis, but also in warehouses. The warehouses are located on two floors and storage of materials was often duplicated on both floors. If the staff find nothing on one floor, then they have to climb the stairs to look in the second warehouse. This not only caused excessive fatigue for the personnel but also the lost time reduced the level of patient safety because of a lack of focus on the immediate process.
Stocks of medicines, disposable materials and equipment in warehouses. Inventories are captured capital that could be used for real improvements. Duplication of orders for items that are in stock occur because inventory is in several different places. Problems with cycle counting and financial losses resulting from excess inventory of outdated drugs. (Note: while medical processes are specific and it is impossible to determine in advance the precise demand for medicines, requirements can still be estimated based on monthly usage. By adding a small surplus called a safety stock, sudden increases in demand will not interrupt continuity of the medical processes.)
Damaged equipment from too frequent movements, improper use and lack of safe storage was reduced by fixed locations and posted instructions.
There were some unnecessary tasks (over processing) such as frequent procurement of goods to the warehouse of the hospital. By consolidation of storage areas and elimination of disorder, procurement of goods by the ward was limited to 4 times a month.
In Table 3 these waste activities are shown with the costs before the changes were made, the costs after the changes were made, and the change’s impact on the waste activities. Note that the processes were not wasteful because of deliberate mistakes; the processes were poorly organized.
By assessing and analyzing the processes at the RCN several potential consequences can be identified. Many of these consequences may contribute to non-added value, negative effects for the patient, and/or reduce the level of quality of medical services. The patient is most important and drives the medical processes. The process of care begins and ends the with the patient, and every process must bring added value for the patient. Reducing the risk of failure of the RCN mission will increase patient satisfaction and decrease complaints. At the start, it was noted that the start of treatment for the patient needs to be on time and the treatment environment must be friendly, clean and safe. This view drives all activities related to our Lean approach.
While the potential for these adverse consequences is recognized, calculating the cost of them is not simple. By not evaluating these costs for this analysis, we have reduced the return on investment. This is a conservative approach to the return on investment for this implementation of Lean. Downstream consequences are mentioned here to indicate that such risks may exist and are reduced by the application of Lean tools.
By adding the costs before and after the change, and taking the difference, a net savings of $110,063 is calculated. Dividing this net savings by the investment results in a ratio of $15.6 return for each $1 invested.
Results and follow-up
In conclusion, visual management has a big influence on quality costs. It is the essential element of communication. Medical staff undertaking patient care take on a huge responsibility, not just for technical oversight of the process but also for improvement of patient’s quality of life. Every word, gesture, writing and audiovisual tool refines the communication and treatment process. Personalizing the level of visual management for different needs and situations helps make the patient feel safe, comfortable and allows the nurse to feel more self-confident.
It should be noted that this project did not cover all of the processes at RCN. The results documented in this case study refer to the hospital section of RCN. Also, the labor cost values in each section (investment, monitoring, internal waste, downstream) were calculated based on median salaries in US dollars first quarter 2016. An indicator on purchasing power parity was based on GDP and related indicators between Poland and US as of 2015 (source: www.stats.oecd.org).
What are the next steps for RCN in building an organization based on the principles and tools of Lean management and costs of quality? As a modern health care organization where the central focus is the patient, plans are moving to deploy additional tools of Lean management. As we do this we are careful to adapt them to our tasks and our work, and the capabilities of our workers.
We have recently implemented the approach of A3 problem solving.A3 was first employed at Toyota and provides a simple and strict approach, systematically leading towards problem solving over structured approaches.
In April 2016 we used A3 in a training program with examples of problems collected from patients and employees at RCN. The tool 5S has been implemented in the physician’s room. Another focus for 2016 was to improve interpersonal communication, looking at high quality three-way communication between patients and nurses, doctors and nurses, and doctors and patients. We continue optimization and organization of the operating theater in accordance with the principles of Lean.
FMEA analysis of several processes is being performed to identify potential points of failure: hemodialysis, peritoneal dialysis, advice for nephrology, advice for diabetes, hospitalization in a nephrology ward, treatment of anemia in predialysis, and reatment of hyperparathyroidism in a patient’s hemodialysis processes. These processes are analyzed with documentation and flowcharts, and processes are corrected if needed.
By using process improvement tools such as FMEA and flowcharts, the RCN processes for hemodialysis, for peritoneal dialysis, and patients in the hospital ward currently receive faster, safer more streamlined care.
- Łazicki A. i in. Systemy zarzdzania przedsibiorstwem-lean management i kaizen [Enterprise-management systems, lean management and kaizen], Wiedza i Praktyka, Warszawa 2011
- 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 pomidzy pacjentem a pielgniark jako element bezpieczestwa procesów klinicznych.[Communication between patient and nurse as element of safety clinical processes], Medical Maestro