Tuesday, March 27, 2007

A Lean machine




Virginia Mason Medical Center in Seattle has become famous as the hospital in America that has most dramatically endorsed the Toyota Lean Production System. The senior administrative and medical team, led by CEO Dr. Gary Kaplan, started the process with a visit to Japan and then designed a hospital-wide program to bring greater efficiency to many aspects of the institution's operations. They entitled their program the Virginia Mason Production System and made significant improvements in many aspects of health care delivery.

At BIDMC, we were not prepared to go quite so far as VM, but we did create a small office to test out the heart of the Lean process, Rapid Process Improvement Workshops. In these short-term intense exercises, a team of people from a variety of jobs categories in a given service or production area get together to map out every step in a customer service or production process. Each step is labeled as "value added" on "non-value added", i.e., with regard to accomplishing the objectives of the area, and then the group decides on strategies to eliminate NVA steps. Then, they actually put them into practice to test their efficacy towards meeting goals of service quality and/or efficiency. Other, longer terms plans and objectives are also decided upon and put in place.

One target area for us was our orthopaedic clinic. Like most clinics, there would be check-in, delays waiting to see a doctor, delays waiting for an X-ray, delays waiting to see the doctor again after the X-ray, and so on. In sum, the average time for a clinic visit was about three hours. Is there any doubt as to why there were disgruntled patients, cranky front-desk staff, frustrated X-ray technicians, and angry doctors?

With great support from our Chief of Orthopaedics, a team was assembled, and they went to work, aided by our Lean coordinator and other helpers. The top chart above shows how many NVA steps (the ones with red dots) were in the "before" process, i.e, the "current state". (Observers often find that over 90% of steps in any service or production process are NVA.) The "final state" chart underneath shows the change in relative NVA and VA steps after the Lean review.

The third chart shows the overall improvement in the amount of time a patient has to spend getting that X-ray and physician consult: Down from three hours to about an hour! Let's repeat that. Previous time for a visit -- 187 minutes. Hoped for target by the Lean team after its analysis -- 84 minutes. Actual results -- 6o minutes or less.

Of course, patients were happy. The staff was very pleased, too. Fewer cranky patients at the front desk complaining about long waits. Efficient use of X-ray equipment and Rad Techs' time. And, doctors being able to stay on schedule all day long. And then being able to add additional appointment slots because they knew they could stay on schedule.

The biggest problem: Patients finished their appointments so quickly that their spouses were nowhere to be found. They were still downstairs at the cafe having a cup of coffee, without enough time to read the whole newspaper!

22 comments:

Anonymous said...

So does this mean you will repeat the process improvements hospital wide? If not, why not?

Paul Levy said...

Not hospital wide. I am not a strong believer in top-down mandates. We want to make sure there is a strong local "champion", like our Orthopaedics Chief. Also, we have limited resources to run these programs. So, we ask for nominations from the various departments and we rank order them according to strategic importance and likely improvement potential.

Toni Brayer MD said...

Congratulations on your results in Ortho and your wisdom to know that champion involvement is crucial for changing work process. All of us in healthcare need to become more efficient and get out the waste....wasted human resources (the most valuable), wasted money, wasted time (ours and the patient's.) This type of process redesign is hard work but worth it.

Anonymous said...

Can you tell us what some of the "non-value added" steps are? I find it amazing that 27 steps can be eliminated from an orthopaedics clinic visit (maybe I don't understand what constitutes a step, but I definitely didn't realize so many steps existed).

Anonymous said...

I, too, would like to know what the NVA steps are. Three hours sounds too long; the last ortho clinic I was in, typical wait was more like 90 minutes (because there was a separate queue to see physical therapy, which about 60% of our patients did).

Paul Levy said...

This is not atypical at all, once a work process is broken down into its components. I will ask one of the team members to answer the specific question.

But, these are not PT appointments. That was another process improvement! These are generally consult visits with an X-ray.

BC said...

Were you able to increase revenue by processing more patients per day? I assume there was no cost reduction if no personnel were eliminated. Increased patient satisfaction could certainly help to attract more patients. What is the variance in processing time, at least among hospitals in the Boston area?

In the Virginia Mason process improvement that was highlighted in a recent Wall Street Journal article, the end result was lower costs for insurers but less revenue (and profit) for the hospital. Ultimately, as I understand it, insurers agreed to increase reimbursement rates for some of the more basic procedures to at least partially make up the difference.

If hospitals are going to be penalized financially for improving work flow, taking cost out of the system (including reduced utilization due to fewer mistakes, etc.), hospitals, insurers, Medicare and Medicaid have some serious work to do on realigning financial incentives.

Anonymous said...

What's with the spelling: "orthopaedics"? Are you changing the hospital name to Beth Israel Deaconess Medical Centre? Don't mean to "criticise" but I'm curious....maybe you can defect and join the National Health Service too...

Alice Lee said...

When we map out the current conditions, we have to first teach the team how to see the waste from our patients' perspective. Toyota has defined waste in several categories and waiting is one of them as is overproduction and wasted motion. Once you understand these concepts, it is easier to root out wasted process steps. For example, why have the medical assistant (MA) walk from the exam room area to the waiting room each time the MD was ready for a patient, take them to Xray's waiting room, walk to the xray control room and call out, "Got one for you!". Instead, we now have the front desk send a "signal" to the MA by printing a label, print an xray req in the xray area and the xray tech comes to get the patient directly. This new process also keeps the MA by the MDs where they are most needed. Key to getting flow was having the xray tech look at a new signal board indicating which MD had an empty exam room and xraying that patient next. Previously, xray measured their efficiency by the speed at which they xrayed a patient from his/her check-in time. That didn't help the Ortho Clinic flow since xray could be overproducing for a particular MD who might be running behind where another MD could be ready and waiting for the next patient to be xrayed.

Ultimately, a key outcome of our Lean initiative in Orthopaedics improved access by adding additional appointment slots. To date, we have added 60 new appts/week to the clinic schedule, 14 of which are next day urgent appts. In fact, we are still adding appts so ultimately in a couple of weeks, we will have a total of 114 new appts/week where 64 of those are next day urgent slots. Before we started the Lean initiative, we had 722 appointment slots per week.

The patient visit time was decreased from over 3 hours to about one hour and has been sustained for 5 months, when we implemented the improvements. Introducing this "flow" was key to improving our access (i.e. adding more appointment slots).

This is a great outcome and impacts throughput (reduced visit time), access (reduced lead time to get appts), and satisfaction (patients, staff and physicians).

Paul is correct, a champion is an important success factor to any change initiative.

Paul Levy said...

To anon 9:20,

Our Chief says that is the correct spelling. I never argue with chiefs.

bc and other anon's,

I think Alice answered most of your questions. bc, you are right to point out the VM insurance problem, which took some negotiations to solve. And, it certainly can be a problem going forward for all of us; so, we will be in close contact with insurers as we make efficiency improvements.

Alice Lee said...

Anon stated, "Three hours sounds too long; the last ortho clinic I was in, typical wait was more like 90 minutes...".

Clarification: Visit time is not the same as the patient's wait time. The 3 hours (and now 1 hour) visit time is a measure of the entire patient's time in the Ortho clinic from the time they check in to the time they check out. That includes the wait time, the xray time, the check in and check out time, and the time with the MD.

Carolyn Kent said...

Paul, how refreshing to see such a successful example of implementing lean in a hospital setting - especially when most other providers refuse to believe it can be done! Way to go, BIDMC!

I am curious as to how you are publishing results to those involved in the Ortho department - do these come in the form of visual reminders around the department, as printed/electronic reports, as verbal summaries in meetings... how do the staff members benchmark their performance?

Anonymous said...

I think the "ae" in orthopaedics is supposed to be a dipthong. Strictly speaking, I think it should be shown as the a and e stuck together. But who knows how to do that??

Anonymous said...

To make æ you hold down the alt or option key and press the apostrophe key. To make œ you use alt Q or option Q.

Alice Lee said...

To Carolyn Kent:

Improvement targets are set when we start a project in an area. The targets are usually very aggressive to challenge the team to completely rethink the existing process. We also measure baseline to know where our starting point is.

We have various measures that we track on a daily basis to measure progress and these are publicly posted where the work is done. In fact, the staff that do the work actually document the data. For example, xray tracks the number of exams they do per hour as compared to number of exams planned per hour (what is scheduled). If the totals for planned vs. actual for the hour don't match, the xray tech documents a reason (e.g. patient not changed, requisition incorrect or unclear). This allows the staff to trend problems over time. The monthly scorecard might show the most frequently occurring problem is the requisition is incorrect or unclear. We then can go through a root cause analysis exercise to further understand the problem for us not meeting our hourly target. We can then make further improvements to address those very specific problems and continue to measure. There are several measures tracked for each area to tell the staff how the process is doing. These are visual, posted, shared. We talk about them at staff meetings also. These are seen as team goals.

Tracking the volume by hour also gives the team an understanding of their demand. We then work together to "level the demand" by reworking how we schedule to keep the patients flowing. These data are very important to this work as improvements are made based on the data and direct observation.

Tom said...

Great post, Paul. I recently finished "The Toyota Way" by Jeffrey Liker, which I was inspired to read after Gary Kaplan's MedPAC testimony. It's amazing stuff.

Paul Levy said...

Thanks, Tom. I agree that Gary is a thoughtful and terrific guy and really pushing the envelope. I can't think of many hospital CEOs who would bet the farm the way he has on this kind of approach to healthcare management. We are all watching closely.

Anonymous said...

Mr Levy,

Clearly Champions are essential to for a test of change. However, once we know what is "good for the patient", at what point do we have to demonstrate a firmer hand and provide top down direction? (Not to be confused with bottom up execution, taking into account local needs, personality, history, politics...).

Mark Graban said...

Mr. Levy-

Congratulations on your improvements and thanks for your public sharing of your results. Keep in mind that Lean and the Toyota Production System are are a management system that goes much further than "kaizen events" (what RPIW's are typically called in the manufacturing world). There are risks and downsides with RPIWs:

1) The excitement of RPIW's sometimes wears off

2) Not every problem is big enough to require a week-long event

3) RPIW's are often scheduled out -- if something is important and needs fixing, why not "now"?

You might be interested in my Podcast with some folks from Seattle's Group Health Cooperative. They tell their story of starting with RPIW's, but then moving into more of a holistic lean management system. They quickly became convinced that RPIW's alone would not make them lean.

Anonymous said...

Patients lives are put at risk by this so called "efficiency." Doctors run tests that don't apply to the patient's symptoms because they're being so "efficient" that they don't have time to take a decent history. Doctors then misdiagnose and mismedicate their patients. When the patients complain of side effects, the physicians still don't have time to listen, so they prescribe more medication to fight the side effects. It's a very efficient way of killing patients. I know - Virginia Mason almost succeeded in killing me. What use is EFFICIENCY without EFFECTIVENESS?
If the first doctor I saw at Virginia Mason had taken a decent history, I wouldn't have lost 7 months of my life recovering from their misdiagnosis.

Anonymous said...

When you considered value and non value added steps was it value to the organization in the form of efficiency or value that added the patient experience?

Paul Levy said...

The focus is on the patient experience, but it leads to changes that help the work environment, too.