Presented by Jacob Edwards

1. Lean Hospitals: Improving Quality, Patient Safety, and Employee EngagementBy: Mark Graban Ch. 9 Improving Flow Presented by Jacob Edwards

2. Processes Should Flow Like a River • Smooth, steady flow through a value stream should be a hospital’s primary goal. • Smooth flow of support products, or smooth flow of patients through the hospital. • Flow improvements do not come from doing the value-adding work faster; they come from reducing and eliminating waiting, interruptions, and delays from the value stream. Jacob Edwards

3. Uneven Workloads as a Barrier to Flow • Many delays for patients and products are caused by uneven workloads. • “Heijunka” – Leveling • One of three foundations of the Toyota house. • Some unevenness in our demand occurs naturally, but a large amount is due to our own policies and choices. Jacob Edwards

4. Mura 1 • “Mura” – Unevenness, irregularity. • Mura Caused by Morning Rounds • Morning rounds by physicians leads to mura for support departments such as the laboratory. • In one lab, 34% of the daily volume arrived in a 3-hour timeframe from 3am-6am. • Also, morning rounds create a spike in patient discharge activity. Jacob Edwards

5. Mura 2 • Mura Caused by Suboptimizing Courier Routes • Labs will get several large shipments of specimens throughout the day. • This led to workers being rushed for periods of time and the labs would have to pay for overtime, • The labs requested smaller samples being delivered from morning to afternoon. • While it was more costly, the labs returned results faster and had less worker idle time. Jacob Edwards

6. Mura 3 • Mura Created by Clinic Scheduling • Outpatient chemotherapy center had mid-day peaks of patients. • Led to delays. • Off site oncologists were creating this schedule to help the patients. • They thought that if the treatments happened earlier, the patients could get home earlier. • The clinic and treatment center created a plan to distribute the chemotherapy patients throughout the day, leveling out the schedule. Jacob Edwards

7. Mura 4 • Mura in the Patient Discharge Process • Discharge delays can keep patients from being admitted into the ED. • When a hospital has a high percentage of Medicare or Medicaid patients, this delay directly impacts the hospitals bottom line. • A hospital estimated that a length of stay reduction by half a day, which is created by delays, would represent a $6 million dollar savings. • Leveling out discharges throughout the day takes away the high load put on other hospital resources. Jacob Edwards

8. Addressing Mura by Matching Staffing to Workloads If workloads cannot be leveled, the next best alternative is to make sure staffing levels vary with demand. Staffing levels and workloads are not always synchronized. By analyzing workloads, staffing can be done to match. Jacob Edwards

9. Improving Patient Flow • Emergency Department • Boarding – Waiting for an inpatient room to become available. • In 2001, 90% of patients waited two hours. • 20% had an average boarding time of eight hours. • Use of the 5 whys helps determine the root causes. • Outpatient Cancer Treatment • Appointment lengths vary creating scheduling issues. • Doctors schedule appointments to have a steady stream of patients which causes a patient backlog. Jacob Edwards

10. Improving Flow for Patient Care and Support Jacob Edwards • Improving Flow in Clinical Laboratories • Lean efforts begin in the lab area because testing volumes are highest and the turnaround time expectations are the fastest and most critical. • Reducing Delays in Specimen Collection • Specimens are grouped into batches and are not submitted individually • Batching makes sense from the nurse and patients point of view, but not the phlebotomist. • Managers must know that the phlebotomist must be treated fairly and cannot be held to a faster standard than others. • This can cause errors with the phlebotomist working at a faster pace.

11. Reducing Delays in the Lab’s Receiving Areas • Specimens arrive at the receiving area. • That area is further divided into an accessioning area and processing area. • In many labs, the processing department is located out of the main flow and specimens must backtrack for testing. • The separation leads to batching, which slows the process. • At the Children’s Medical Center of Dallas, Texas, the accessioning and processing departments were combined into a single area. • Employees of the labs were cross-trained and the result was sample time being reduced from 30 minutes to 5-10 minutes. Jacob Edwards

12. Improving Flow Also Improves Quality and Teamwork • When batches are created, the same defect can be created for every specimen. • With single piece flow, a defect can be caught immediately, preventing the accumulation of defects. • Benches were created where specimens were processed and centrifuged by a lab assistant who the then handed the specimens across the workbench to the technologist. • This led to increased communication and allowed immediate feedback. • Also, the lab equipment was easily accessible to both the lab assistant and the technologist. Jacob Edwards

13. Improving Flow in Pharmacies • Technicians may walk miles per day because tools they use may not be located in the same area. • If the pharmacists are separated from the technicians, batching can occur. • If meds are prescribed for a patient in multiple doses per day, it is better to send them dose at a time and not all at once. • Memorial Health of Savannah, GA, redesigned their pharmacy to reduce wastes and improve response times. • Staff of the hospital rated the redesign and the service of the new pharmacy highly. Jacob Edwards

14. Lean Lessons (page 175) Make improvements that remove rocks instead of covering the problems with more water (workarounds or waiting queues). Single-piece flow is a direction, more than an absolute mandate. Unevenness in flow can be the result of natural occurrences or our own policies. Lean teaches us to not accept mura as a given. When flow is interrupted, ask why and fix the systemic causes of batching or other delays. Improving flow often improves quality and teamwork. Faster is not always better, depending on the customer needs. Jacob Edwards