Factory Efficiency Comes To The Hospital - The New York Times

05/01/2017
FactoryEfficiencyComestotheHospitalTheNewYorkTimes
BUSINESSDAY
FactoryEfficiencyComestotheHospital
ByJULIEWEED JULY10,2010
SEATTLE
TWOyearsago,thesupplysystematSeattleChildrensHospitalwasso
unreliablethatSusanneMatthews,anurseintheintensivecareunit,would
stockpilestuffcathetersinthecloset,surgicaldressingsinpatientsdresser
drawersandclampsinthenursesoffice.Andshewasnttheonlyone.
Nursesgetveryanxiouswhenwecantgetourhandsonthetoolsweneed
forourpatients,Ms.Matthewssays,sowegrabbedthemwhenwesawthem,
andstashedthemaway.This,inturn,madetheshortagesmoreacute.
OnabusydaylastmonthintheI.C.U.,ittookMs.Matthewsjustafew
secondstofindthespecializedtubingsheneededtodelivermedicinetoaninfant
recoveringfromheartsurgery.Thetubingwasnearby,inafullystockedrack,
thankstoanewsupplysysteminstitutedbythehospitalearlylastyearfollowing
practicestypicallyusedinmanufacturingorretailing,nothealthcare.
Therearetwobinsofeachitemwhenonebinisempty,thesecondispulled
forward.Emptybinsgotothecentralsupplyofficeandthebarcodesarescanned
togenerateaneworder.Thehospitalstoreroomisnowhalfitsoriginalsize,and
fewersuppliesarediscardedforexceedingtheirexpirationdates.
ThesystemisjustoneexampleofhowSeattleChildrensHospitalsaysithas
improvedpatientcare,anditsbottomline,byusingpracticesmadefamousby
Toyotaandothers.Themaingoalsoftheapproach,knownaskaizen,areto
reducewasteandtoincreasevalueforcustomersthroughcontinuoussmall
improvements.
http://www.nytimes.com/2010/07/11/business/11seattle.html
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Manufacturers,particularlyintheautoandaerospaceindustries,havebeen
usingthesemethodsformanyyears.AndwhileasickchildisntaCamry,Seattle
ChildrensHospitalhasfoundthatchecklists,standardizationandnonstop
brainstormingwithfrontlinestaffandcustomerscanpayoff.
Itturnsoutthehighestqualitycarealsoisthemostcosteffectivebecause
wemakefewermistakesandcreatebetteroutcomes,saysPatrickHagan,the
hospitalspresident.
Theprogram,calledcontinuousperformanceimprovement,orC.P.I.,
examineseveryaspectofpatientsstaysatthehospital,fromthetimetheyarrive
intheparkinglotuntiltheyaredischarged,toseewhatcouldworkbetterfor
themandtheirfamilies.
Lastyear,amidrisinghealthcareexpensesnationally,C.P.I.helpedcut
SeattleChildrenscostsperpatientby3.7percent,foratotalsavingsof$23
million,Mr.Hagansays.Andaspatientdemandhasgrowninthelastsixyears,
heestimatesthatthehospitalavoidedspending$180milliononcapitalprojects
byusingitsfacilitiesmoreefficiently.Itserved38,000patientslastyear,upfrom
27,000in2004,withoutexpansionoraddingbeds.
Similarmethodsarenowinplaceatotherhospitalsandhealthsystems,
includingBethIsraelDeaconessMedicalCenterinBoston,ParkNicolletHealth
ServicesinMinneapolisandVirginiaMasonMedicalCenter,alsoinSeattle.So
manyothershavecalledforadvicethatSeattleChildrensputtogetheratwoday
workshop,presentingittomorethan200medicalworkersandhealthcare
leadersfromtheUnitedStatesandEurope.
Somepeoplethinktheyhavetochoosebetweenqualityofcareandsaving
money,saidDr.DavidChand,whoattendedthetrainingandnowusesC.P.I.
methodsatAkronChildrensHospitalinOhio.C.P.I.improvesbothpatient
outcomesandthehospitalsbottomline.
Toincreasethenumberofsurgeriesthehospitalcouldperform,Dr.Chands
teamspentabout$20,000overhaulingtheprocesstosterilizeinstruments,
avoidinga$3.5millionexpendituretoexpandthatdepartment.Moreefficient
schedulingintheM.R.I.departmentreducedtheaveragewaitingtimefornon
emergencyM.R.I.sfrom25daysto1to2.
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Allmedicalcenters,especiallylargerones,wouldhavesignificantreturnon
investmentbyusingoperationsmanagementtechniqueslikeC.P.I.,saysEugene
Litvak,presidentandchiefexecutiveoftheInstituteforHealthcareOptimization
andanadjunctprofessorofoperationsmanagementattheHarvardSchoolof
PublicHealth.
Thehealthcareindustrycouldbeonthevergeofanefficiencyrevolution,
becauseitiscurrentlysofarbehindinapplyingoperationsmanagement
methodologies,saysProfessorLitvak.
TObesure,noteveryonebelievesthatfactoryfloormethodsbelongina
hospitalward.
NellieMunn,aregisterednurseattheMinneapoliscampusofChildrens
HospitalsandClinicsofMinnesota,thinksthatmanyofthechangesinstitutedby
herhospitalareinappropriate.Shesaysthatinanefforttoreducewaste,
consultantsobservedherandhercolleaguesandtriedtodeterminetheamountof
timeeachoftheirtasksshouldtake.Butproceduretimescantalwaysbe
standardized,shesays.Forexample,somechildrenneedtobecalmedbeforeIVs
areinsertedintotheirarms,orparentsmayneedmoreinformation.
Theessenceofnursing,shesays,ismuchmorethanasumoftheparts
youcanobserveandwritedownonawallfullofstickynotes.
OnJune10,Ms.MunnhelpedleadaonedaystrikebytheMinnesotaNurses
Associationagainstsixlocalhealthcarecorporations,includingheremployer,
partlyinprotestoflowerstaffinglevelsherunionthinkshaveresultedfrom
hospitalsleanmethods.Wefeltthecutscreatedanunsafeenvironmentfor
patients,shesaid.ThenursescontractwassettledonJuly1,withnoincreasein
stafflevels.
BrianLucas,aspokesmanforChildrensHospitalsandClinicsofMinnesota,
saystheleaneffortshavebeenusedtoreduceunnecessarytasksandhavenot
resultedinlowernursetopatientratios.Tothecontrary,hesaid,theyhave
allowednursestospendmoretimedeliveringcaretopatients.
TechniqueslikeC.P.I.mayindeedbehardformanyhospitalstoputinto
effect,saysMarkGraban,aseniorfellowattheLeanEnterpriseInstitute,a
nonprofitresearch,educationandpublishingcompany.Theprocesstakesalarge
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amountoftimeandrequiresacultureshiftthatmanyhospitalsmaynotbeable
toaccommodateorsustain.Iftheleadershiptriestoforcenewwaysofdoing
things,thestaffmaychafeunderthesuccessivechanges,hesays.
AndGeorgeLabovitz,amanagementprofessoratBostonUniversity,says
therearelimitstoperformanceimprovementmethodsinhospitals.Human
healthismuchmorevariableandcomplexthanmakingacar,hesaid,soevenif
youdoeverythingright,youcanstillhaveabadoutcome.
Physicallayoutscanalsointerferewithchangesthathospitalswanttomake,
likereducingthedistanceachemotherapypatienthastowalk.Andthe
techniquescanfallshortoftheirpotentialiftheyareusedinjustoneareaofa
hospital,becauseapatienttypicallymovesthroughmanydifferentdepartments.
AtSeattleChildrensHospital,Dr.JohnWaldhausen,thedivisionchiefof
pediatricgeneralandthoracicsurgery,acknowledgesthatheandotherdoctors
werentinitiallyveryenthusiasticaboutC.P.I.becausetheythoughtitwouldtake
somedecisionsaboutpatientcareoutoftheirhands.
Overtime,hechangedhismind,andheisnowavocaladvocateofC.P.I.
Whenyoulookclosely,C.P.I.isthesamescientificmethodwelearnedin
medicalschool,includinghypotheses,datacollectionandanalysis,hesays.Itis
notopinionandconjectureitisdatadriven.
TENyearsago,SeattleChildrenssetagoaltobecomethetophospitalofits
typeinthecountry,andhiredJoanWellman&Associates,aprocess
improvementconsultingfirminSeattle,tohelpitgetthere.Ms.Wellman,who
hadworkedwithBoeingonitsleanmanufacturingprocesses,suggestedthatthe
hospitalapplysimilarprinciples.
Mr.HagansayshebecameenthusiasticaboutleanmanufacturingandC.P.I.
afterdoingresearchandvisitinglocalmanufacturers.Hedirectedthehospital
stafftoexaminetheflowofmedicines,patientsandinformationinthesame
waythatplantmanagersstudytheflowofpartsthroughafactory.
InatypicalworkshopatSeattleChildrens,agroupofdoctors,nurses,
administratorsandrepresentativesofpatientsfamiliessetasidea40hourweek
toworkthroughC.P.I.methods.Theyploteacheventapatientmightencounter
likefillingoutforms,interactingwithcertainstaffmembers,havingtowalk
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variousdistancesorhavingtowaitforassistanceandbrainstormabouthow
eachcouldbeimproved,oreveneliminated.
Thehospitalstaffhasbeenrollingouttheprograminstagesoverthelast
decade.Wehaveprobablymadeover1,000smallchanges,andfranklyitnever
ends,saysMr.Hagan.
InhisC.P.I.training,Dr.BryanH.King,directorofthedepartmentof
psychiatryandbehavioralmedicine,wasoneofthefirstSeattleChildrensstaff
memberstovisitJapanesemanufacturers.Helearnedthatwastecouldbe
viewedasanyactionthatdidntaddvaluetothecustomer.
Turningtohispsychiatricinpatientunit,heandhisteamworkedtopinpoint
thegoalofeachchildsstayandtocommunicatedailywithfamilies.Theyalso
madeotherchanges,likestartingtoarrangeoutpatientresourcesassoonas
childrenentertheunit,ratherthanwaitinguntiltheyarereadytoleave.These
kindsofchangesincreasedsatisfactionratingsfromfamiliesandhelpedcutthe
averagetimeinthehospitalfrom20daysto10.Theunitcannowaccommodate
650childrenayearinsteadof400.
Changeslikethesearecelebratedbythehospitaladministration.Their
supportfosterstheideathateveryonecanmakepositivechangestotheir
departments,Dr.Kingsaid.
Dr.HowardE.Jeffries,thehospitalsmedicaldirectorofC.P.I.,isafanof
visualaids.Onefavoriteisawhiteboardattheentranceofthecardiacintensive
careunit.Amapoftherooms,labeledwithpatientnames,providesaquickstatus
reportonhowfulltheunitisandhowillthepatientsare.Stickonstarsindicatea
patientwhoneedstobeinisolationabluecircleshowsapatientonaventilator.
Ataglance,staffcominginfortheirshiftcangetanideaofwhatsgoingon
andwhattobeawareof,Dr.Jeffriessays.
Thesametypesofvisualcuesareusedforinventorylevelsorinspection
statusinfactories.
AnotherofhisfavoritesistheDaysWithoutInfectionposter,likea
constructionsitesDaysWithoutanAccidentsign.Itkeepsournewsafety
protocolstopofmindforpeople,hesays.
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StandardizationisalsoaC.P.I.cornerstone.Lastyear,10surgeonsatSeattle
Childrensperformedappendectomies,andeachdoctorwantedtheinstrument
cartsetupdifferently.ThesurgeonsandothermedicalstaffmembersusedC.P.I.
tocomeupwithacarttheyallcoulduse,reducinginstrumentpreparationerrors
aswellasinventorycosts.
Dr.LynnD.Martin,directoroftheanesthesiologyandpainmedicine
department,sayschangespreviouslywereinstitutedonlywhenexistingsystems
failed.UsingC.P.I.,teamscannowmakechangesanytimetheythinktheycan
improveaprocess.Whentheoperatingroomteamsawthatatonsillectomy
procedureinvolvedfillingout21separateforms,itsatdownwiththeprintvendor
toremoveduplicationsandcutthenumberto11.
Thestaffdoesnthavetowaitfortheperfectsolution,Dr.Martinsays,justa
betterone,becausetheycankeepmakingimprovementsyearafteryear.
UsingC.P.I.,thehospitalhasreducedthewaitingtimeformanysurgeries
fromthreemonthstolessthanone.Recently,thebottleneckwasnotthe
surgeonstime,butalackofavailableinpatientbedsforrecovery.Examiningthe
hospitalscensus,administratorssawthattherewereemptybedsonweekends.
TheyrealizedthatbyschedulingmoresurgeriesonFridays,patientscould
recoverovertheweekend,whenmorebedswerefree.Thechangealsobenefited
parentsandpatientswhowouldmissfewerworkandschooldays.
Lackofspaceintherecoveryroomwasanotherlogjam,andthehospital
planneda$500,000renovationtoenlargeit.ButaC.P.I.teamsawthatifa
childsparentswenttoacommonwaitingroomduringsurgery,insteadofan
individualrecoveryroom,moresurgeriescouldbescheduled.Parentsweregiven
beeperstoalertthemwhentheirchildwouldarriveintherecoveryroomand
mapsandcoloredlinesonthewallshelpedpointtheway.Plansfortheexpensive
renovationhavebeenscrapped.
INthehospitalslargestC.P.I.projectyet,LisaBrandenberg,thechief
administrativeofficer,usedthemethodtodesignanew$70millionclinicand
surgicalfacilityinBellevue,Wash.,justeastofSeattle.
Medicalbuildingsoftenhavestandardbenchmarksbasingthenumberof
examinationrooms,forexample,ontheexpectedvolumeofpatients.Ms.
BrandenbergandherteaminsteadusedC.P.I.tomapoutcommonpathsthat
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patients,staffmembers,suppliesandinformationwouldflowthrough.They
workedinanemptyofficebuilding,usingcardboardmockupsofsurgicalsites,
recoveryrooms,anesthesiaareasandwaitingrooms.Fiftystaffmembersthen
playactedvariousscenariostotestthedesignseffectiveness.
Thefinaldesignreduceswalkingdistancesandwaitingtimesforpatientsby
groupingrelatedfacilitiestogetherandcreatingroomsthatcanbeusedformore
thanonepurpose.Thehospitalwasabletoshave30,000squarefeetand$20
millionoffofthenewbuilding,whichistoopenJuly20.
Wecantwaittoseeitinuse,saysMs.Brandenberg.
Correction:July18,2010
AnarticlelastSundayabouthospitals'useofefficiencytechniquesoftenfoundin
manufacturingmisspelledthesurnameofamanagementprofessoratBoston
University,whosaidthattherewerelimitstoperformanceimprovementmethodsin
hospitals.HeisGeorgeLabovitz,notLebovitz.
AversionofthisarticleappearsinprintonJuly11,2010,onPageBU1oftheNewYorkeditionwith
theheadline:FactoryFinesse,attheHospital.
2017TheNewYorkTimesCompany
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