Is the Answer Right There in Front of You?

A couple of weeks ago, I was looking at our workload data and noticed that 47% of our stat testing was coming from our attached nursing home. This seemed like an oxymoron to me. How could nearly half of our requests for stat testing be coming from a long term care unit that should not have patients with acute illness issues?

I shared the information with the staff at our next morning's huddle. They were also surprised by the high percentage, but nothing further was said about the issue at that time. Later that day, however, our Point of Care supervisor, in charge of our glucometers mentioned to me that the stat orders were for the confirmation of high glucose results. Our glucometer policy stated that any glucose fingerstick result greater than 400 mg/dl required a laboratory confirmation. Indeed, the majority of the stats were for confirmations! I should have noticed this, but did not. I was not close enough to the front line for it to click!

The supervisor also reminded me that the manufacturer's recommendations for the new glucometers did not require a laboratory confirmation until the result was greater than or equal to 500 mg/dl. I had completely forgotten that! When we installed the upgraded glucometers, we had made a quick decision not to change our policy because it would require a change to the policy for the nurses and any laboratory-nursing policy change takes a long time and a great deal of effort to implement. This definitely was worth a second look. It would decrease the number of stats that they laboratory would need to respond to, decrease the nurses needing to order a glucose lab confirmation, decrease reagent use, and decrease the time for the nurse to respond to the high glucose. It would improve the quality of patient care and decrease cost at the same time.

We did a correlation study to make sure that the fingerstick glucoses between 400-499 mg/dl correlated well with the lab confirmations. They did and it proved to us that we could change the confirmation of fingerstick glucoses to greater than 499 mg/dl. The solution to the high number of nursing home stats was there all the time, but I could not see it. Yes, the answer was right there in front of me, but it took a staff member closer to the issue to point it out. A perfect example of how Lean initiatives can decrease waste, while improving quality, and it took a front line worker to see it!

It's About the Worker

The thing that I like the best about Lean thinking is that it is all about the worker. They are the ones that can see what needs to be improved because they are at the front line where all the good and bad parts of a process are glaringly obvious. Lean celebrates this by empowering the entire organization to listen to the worker.

In old style, top down management, when an employee made a suggestion, it was usually ignored. Management felt that the employee could not possibly have a better idea than the standard system. In fact, Management was conceited enough to think that 'they' had all the answers. How terribly wrong this concept was!

Through Lean education, the organization learns to value the worker's input. Not only is it valuable, it is essential, because Management does not see the intricacies of the day in and day out operation. Sure, Management aggregates data, initiates Lean processes, communicates the changes, and measures the successes and failures; but Lean would be nothing without the worker.

It is time that organizations value the worker for what they are: the heart and soul of their company. In my little department, we have only 24.4 FTEs, but together it adds up to over 500 years of experience. I defy any manager to match that sum of knowledge.

Our First Results

We focused some of our efforts on our inventory. We have little storage space and looked for ways to decrease our inventory on hand. We have one inventory aide (out of 24.4 FTEs) that does our ordering and restocking. She began to decrease her order size over time and at the end of the year we took our fiscal year end inventory.

In 2007, our year end inventory totaled $97,102. In 2008, it totaled $52,365. We had reduced our inventory by $44,737 in one year!

I was amazed and celebrated the success with our inventory aide, who had been instrumental in the change. I ordered a bouquet of flowers from the local florist, purchased a gift card, and asked our CEO to join me in delivering the thank you. The inventory aide was shocked that we had acknowledged her hard work and she was overwhelmed with our thank you. It was well deserved.

The Beginning

Last year, we began the process of creating a Lean Lab. Our hospital does not have a lot of money because we are relatively small, 87 beds, but I knew that anything that we could do would be of benefit. We had hoped to remodel the laboratory and I hired Pat Maul, MBA, MT(ASCP), Principal Consultant and Lean Sigma Black Belt of BD Diagnostics, to assist us in our process. Pat introduced the Lean concepts to the laboratory and began the process of redesigning our floor plan. Our current floor plan consists of each department in a separate room. Specimen and tech flow are choppy at best. Communication between the various rooms is difficult.

The new floor plan is an open lab with all the clinical departments in one room. Pathology, Histology, and Cytology are not included in the open lab, but are conveniently located next to the main lab. We roughed in the floor plan, and waited for the go ahead from administration to hire an architect to produce the blue prints. In the meantime, we began the internal Lean process by beginning daily meetings (or huddles) at 11:00 a.m., worked on 5S initiatives, and began to look for waste (muda) that brought us no value. Our lab began to look cleaner, more organized, and our team began to come together to focus on one mission: to put the care back in health care.