Lean Just Keeps Popping Up!

Our Lean project had detoured the last year or so due to a change in hospital leadership. Remodeling in the Lab was stalled and our Lean project began to drift.

Today we had a management team meeting on the results of our hospital's AHRQ Survey on Patient Safety Culture. We had taken the survey first in 2009, and then again this year, 2011. The 2009 results were never shared with the management team, and to no surprise, the 2011 results were pretty much unchanged. Like I said, we had a change in leadership, so there was some lost time last year where not much happened in our organizational development.

We began to discuss the next steps in improving our culture of patient safety and guess what, 'Lean' was mentioned! It was mentioned in the context of department quality work groups and the process improvement cycle. Time to dust off our templates and begin again.

Yes, that 'Lean' just keeps popping up. Just like the flowers in the Spring. Once a seed is planted, the growth is inevitable. With a little water and fertilizer maybe we will see some growth this time around.

Lean Coach vs Technical Supervisor

I was talking with a CFO from a Midwestern hospital today about transforming supervisors into Lean coaches. Dave Krebs (http://www.leanhealthcareexchange.com/?p=874) does a nice job in discussing how a sports coach is similar to a Lean coach. In the laboratory environment there are two kinds of supervisors: technical supervisors and staff supervisors, which may complicate the process in transitioning to a coaching environment.

To automatically assume that a technical supervisor should become a Lean coach is a huge leap. A technical laboratory supervisor is in charge of a particular department or area of the laboratory. It usually is one whole department, such as Chemistry, or Hematology, or Microbiology. This type of supervisor is in charge of the technical operations: instrumentation, adding new testing methodologies, quality control, maintenance, proficiency testing, correlations, etc. They may or may not have staff responsibilities and some technical supervisors prefer to manage the technical environment more than the people working in the lab.

One of the reasons that some medical technologists have such a hard time with people skills is because there is no emphasis on management or manufacturing in their training at the college level, nor in their registry exam, and hence the student does not value learning any of those skills. Once graduated and employed, the employer must bear the burden in teaching the new tech these important concepts, which is time consuming and expensive.

When I worked at Allina Health System in Minnesota, we had technical consultants that filled the technical supervisor role and then we had Site Managers that were in charge of hiring/firing, evaluating, and scheduling the staff. In this environment, it would be easier for the Site Managers to become the Lean coaches, and they may be better suited to the role.

There certainly needs to be an open collaboration between the technical supervisor and the Lean coach, but to have separate roles may enhance the Lean process. It would allow two points of view to analyze a particular process; one focused internally on the operation of the instrument; and one focused on the processes that produce the product, the data. Smaller hospitals may not be able to afford the luxury of having staff for both roles. In that case, selection of Lean coaches will be more challenging.

Laboratorians need to dialog on these topics and share successes professionally. Our careers will depend on it.

Our Lean Effort Has the Flu

Just like any other change effort, when we get busy, we struggle with maintaining the change. This seems to be especially true this week with the influx of patients with symptoms of influenza. I am just going to forgive us for not staying on track and hope for better times in a few days.

Over the last few days, our morning huddles have been non-existant. We are short staffed. I have been in many meetings that seem to last beyond their allotted time, and more pressing questions about testing patients for influenza have taken up our time to work on our Lean projects.

I share this because I am assuming that many other healthcare organizations are dealing with the same thing. This does not mean that we are not doing our job. Part of our job is to prioritize and to address what is most important to patient care. This week it just happens to be in the middle of a growing epidemic of influenza.

What I have noticed, however, is that we are working together better as a team. We are communicating with each other in a positive way, using active listening techniques, forgiving each other when a policy decision changes based on new information and supporting each other in the hectic environment. Even though our individual Lean projects may be temporarily on hold, we are still making a positive difference for our organization, and that feels good.

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!

Lean is Contagious

When we started our Lean project in the laboratory, very few people knew much about Lean initiatives at our hospital. We have been whittling away at various issues and little by little, we are moving forward. Last week I shared a little of our success with our management team. I kept it simple, defined waste and value, and talked about how easy it can be to gain some wins. You see, like most hospitals right now, we are looking for ideas to reduce expenses, and we are starting to run out of ways to do this. I thought it was a good time to show them that there is more than one way to skin the cat of saving money.

After the meeting, the administrator of our 100 bed nursing home invited me to give the presentation to his staff. The next week, one of our nurse managers e-mailed me to say that she had purchased the book Lean Thinking (see reference listing below in my Lean Library)!

Today I stopped by the CEO's office for a moment and he mentioned that he was thinking of inviting a lean consultant to help us in the OR. We are having some scheduling problems because we have gained some surgeons at the hospital recently and the juggling of the OR rooms is getting to be a challenge. He thought maybe a Lean expert could help us.

Lean is contagious. I think it is because it takes the focus off of the dollars and places it back on the patient and solves two problems at once. In mathematical terms I would say, "cost reduction + process improvement = Lean".

Is this the Right Patient??

In 1998, when I started to work in my current position, the laboratory medical technologists said that one of the biggest problems they were having was that the patient wristbands were either missing or unreadable and asked me to help them with this. As a laboratorian, I was trained to get the right results, on the right patient, in the right amount of time, to right the physician. This concept seems simple enough, but it is not so easy when you deal with the myriad of challenges that a busy hospital deals with each day.

My first step was to benchmark our problem, and luckily the College of American Pathologists offered a Q-Track(TM) (http://www.cap.org/apps/docs/q_probes/past_studies/1993/wristband_identification_error_reporting.pdf) quality measurement tool in 1999 on exactly this problem. Six times a month, our phlebotomists gathered data on all the inpatients that they drew blood from, on whether they had a wristband on, and if it was readable and accurate. Each quarter we sent in our data to benchmark against the other hospitals that were participating in the study. Our results for that first measured quarter showed that we had a 12.9% wristband error rate. This confirmed what the technologists had believed to be true. We did have a problem.

I took the data to our CEO and discussed it with him and he asked me to share it with our Director of Nursing. When I spoke with her, her response was, “Well, every hospital has a problem with this, and we are no different.” Then I showed her the benchmark data on how we compared to other hospitals nationally. It was indisputable. We did have a problem. She asked me to begin an interdepartmental process improvement (PI) team to tackle the problem.

If I had not had the benchmark data, I would have never been able to get this PI project off the ground. It was a great communication tool and made it much easier to get full administrative support to tackle the problem.

Ten years later, we still measure the wristband error rate using the same Q-Track(TM) program. We still gather data six times a month to benchmark against the hospitals that continue to participate in the study. We now have a wristband error rate of less than 1%.

I believe that this is one parameter that we can never stop measuring. We need to measure what matters and patient safety is at the top of the list.

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.