It’s an Election! I like a good debate, but I am not a fan of a negative campaign. Not long out of the election gate, “Lean” was on the chopping block for one political party, and perhaps to be scaled down some by the ruling party.
Though never a “Lean Leader” I have seen enough to have an educated opinion of the Lean journey. Our Health Region was first out of the block to explore this way of looking at systems, processes and change and some very good changes have come out of that system. After a few years of this region doing some Lean initiatives, the Saskatchewan government rolled it out big time, with timelines set ( ? realistic ?) and other Health Regions began their own programs. There are some parts of it that are great, some good and there could be some that don’t “add value” to our health care system.
In my career, health care has gone from Quality Assurance (essentially tracking safety performance but never really thinking out of the box) to Quality Improvement ( random ideas on how to improve but often without staff input and accountability) to the latest adoption of Lean Methodology and Kaizen Promotion Teams. To me this is the most effective of all the programs I have participated in. There is always something to improve in a system that is so diverse and full of potential risk.
So what is all the criticism and is it true ? Were the staff paid to speak Japanese and fly airplanes ? Did millions of dollars go down the drain without any effect on quality ?
TRUE: All staff were obligated to attend a ½ day session to learn the jargon that goes with Lean and to understand some of the processes and innovations that were to come. In most workshops one attends there is usually some kind of a game to illustrate the learning, and the paper airplanes did help us to see how teamwork and buy in could make a difference. Did all buy in ? Of course not, but it was a good way for us to understand some of the basics of the program.
TRUE: Fancy Japanese names and processes? Let me explain simply …
3S – This is basically “everything in its place and a place for everything”. Nurses love to hoard. We hide linen away and supplies away “just in case”. It is like we all grew up in the Great Depression. Hence, cupboards get full, people decide on a new place to house important equipment – and the chase goes on. “Where are we keeping the dressing supplies now?” or “where did the lift slings go to?” are common time wasters in a health care staff’s day. Everyone has a better idea on storage, and if they find spare time, get to sorting and cleaning and moving thing around. Imagine if equipment and supplies had a home, and it was clear where they went and everyone agreed that it was a good place. What if we checked periodically that something didn’t go rogue? A good thing and it seems like common sense but in all the places I have worked as a nurse in 45 yrs standard storing of supplies has been a concern. Oh how many steps I have travelled to find an item gone rogue.
Kanban: This is simply described as a push system instead of a pull. Staff in health care spend several hours every week ( and sometimes more often ) to count inventory and send a requisition to “Stores”to refill their supplies. Imagine ( and actually see !! ) a system where instead of ordering and counting, there is a line in the sand where the supplies are too low, and the supply department fills it from just looking at what is at the low. ( Of course buildings not within the hospital still have to order, but the line is clear where new supply is needed) Our new hospital has an amazing storage system where supplies are kept in the room and accessible from both sides. Filled from the outside, used from both sides. That was created through Lean processes.
3P – The process where people ( executive leaders, doctors, nurses, housekeeping staff, dietary staff and even patient representatives get together and look at potential flow, potential room size, and generally every area of the hospital. For example, the pediatric ward, a mother of a child who had been in hospital was on the team. Was the process perfect ? no far from it . But with this process, people began to compromise, brainstorm and work together to solve problems that exist and might exist. As with every project, this can have some fails. Ours was the 2nd 3P project in the province ( the other one being the Children’s Hospital ) so we are in a brave new world.
Several Lean processes are put into place to evaluate a “Kaizen Event” ( or improvement process ) Lean looks at a process from beginning to end and all the tasks and people involved in it. Work is measured. If one knows the average time it takes to do a task, we can figure out what things prevent that timing from happening, and we can standardize the work. ( something like the timing estimates on your favourite recipes.) Then we can “load level” to patient demand – meaning if I am overly busy, there will be a system to flag that I need help. Think of a line up at grocery store.. when it gets to 5-6 at a till, someone calls for a till to be opened, and things move quicker). Health care can do the same kind of things and will continue to improve processes until they feel they are doing just that.
Kaizan projects look at problems and work to find solutions. Solutions come from staff that have never worked your department in consultation with staff that do. These take up a lot of time, so choosing a project is vital to having a successful Kaizan project. It isn’t a manager telling staff a process has to change, it is staff brainstorming with the leaders and coming up with the best way – which then becomes standard work. The other blessing is sometimes we wait till the perfect time to change something – and that never comes. With these projects the question is “how can we make that happen today?” And the change begins.
Procedures become Standard Work – more than just a name change. Everyone knowing what has to be done, in what order and no “individualizing of procedures”. Nursing in the past has often been a “but I do it this way” kind of system. Not with lean.
Mistake proofing looks at high risk procedures and making sure mistakes don’t happen.
So if done right Lean makes sense, and saves waste ( of time, materials and workload). But sometimes, when we think of different ways to do things, the solution isn’t right.. and that is where the team goes back to the “table” and looks at other solutions. Sometimes no improvement is seen. And sometimes the changes are not an improvement.. but overall the process works.
Consultation with Lean consultants has made the Lean process in our region a well oiled machine. What are the results? Shortened surgical wait times, better pre op assessment, increased services in mental health, shortened wait for assessment for long term care and home care, better scheduling, processes to ensure the right patient gets the right procedure, foolproof identification of patients ( are you tired of giving out your birthdate yet ?) are just a few. And if you look beyond the hype and criticism you will see that we now have a hospital to be very proud of.
Shortened wait times you say ? What about our Emergency department – well sitting in a crowded waiting room or a room in the emergency for 4-6 hours is certainly distressful, and I have been there – but both times we had to go to Emergency since the new hospital opened, we got immediate and competent attention.
Long wait times are a problem all across the country. One of my most difficult decisions is deciding when Emergency is the right place to go to. I agonized over this as I am sure many reading this do as well.
Emergency departments are often used because of poor access to walk in clinics and for those who work and can’t take time off during the day to look into minor health concerns. Many times the waiting room becomes a social time for family and friends to visit while waiting, in areas not designed for this. In a perfect world, waits would not happen, people would have better access to non urgent care and time off work to access it and everyone visiting the Emergency department would be seen in ½ an hour. In Canada, Saskatchewan, and in Moose Jaw we just are not there yet.
My experiences in hospitals both working, being a patient, and being a family member have not always been positive, and I believe that using Lean we are looking at solutions for concerns. Recently when I expressed a concern, I saw those Lean processes go into play and a willingness on the part of the manager to try a different way of doing business.
Our health system is far from perfect but staff and management are working together to solve the problems. I think to throw out Lean is to throw out the baby with the bath water.
I believe that the 3P process gave us a wonderful building we can be all proud of, and I believe that when staff and managers get more used to their totally new environment and processes, there will be great things to come. When a concern is taken to the Quality Care Coordinator, people are ready and willing to find a solution. I know.. I have been on both sides of having a problem taken to them.
Have I made this more clear ? I hope so !