Wednesday, September 09, 2009

MICUs go Lean: Result = Happiness

Continuing our spread of Lean process improvements, a team recently assembled to use the 5S process to redesign the supply rooms in two of our medical intensive care unit ("MICU") supply rooms. The objective was to standardize the arrangement and display of supplies in the two rooms, which are on two separate floors. Beyond making each room more efficient, we wanted them to be identical because the same staff people work in the two units. It is better for them to see supplies in the same configuration in the two venues. The plan was to organize items to make the supply collection process more intuitive and also to require less motion. After all, these are intensive care units, and people can often be in a hurry when supplies are needed. Time matters.

And beyond one quick fix, we were looking for sustainability, an organization and process that would keep the units well organized and neat well into the future.

As always, this Lean project was multidisciplinary, involving attending physicians, residents, nurses, respiratory therapists, patient care technicians, and our supply and distribution folks. Able assistance was provided by our Business Transformation unit (aka "Lean Team"), but also people from other units who had conducted similar improvement events on their floors.

The results:
-- 100 distinct, unnecessary items were removed from the supply rooms.
-- 86 frequently used items were converted to par items (i.e., restocked regularly, rather than being called for as needed.)
-- 100% identical supplies in the two supply rooms. See Venn diagram above for the before and after.

But, most impressive, the amount of time accumulating supplies for a given procedure was dramatically reduced. See these before and after videos of nurse Tim collecting arterial line supplies. And then view the third video for Tim's triumphal conclusion!

video


video


video

29 comments:

Doug Bryan said...

Hey Mr. Levy,
I'm an MHA student with an interest in healthcare improvement. I really enjoy your blog...
I've got a few questions about the MICU project. What prevents the stockroom from returning to the "before" state. If the stockroom went back to the "before" state what would be most likely happen? Would anyone, besides those in the MICU, know? How would they know? Would anyone be held accountable?
I would love to hear your thoughts if you get a chance.
Thanks

Anonymous said...

Haha, Doug read my mind! From experience, I wonder what will prevent "drift", say when you get a new nurse manager on one of the floors who decides the stockroom needs re-organizing on her/his terms.
How are these changes codified for new personnel?
(NOT that I'm criticizing - these are important advances that are way overdue in hospitals!)

nonlocal

Keith said...

Bravo!

Better efficiency in heath care. Now I understand why you CEOs of health care organizations are paid so much. Shame on me for wondering all these years what warrented paying someone 1.5 million a year to be a hospital CEO. Obviously a challenging job trying to get those unerlings to organize the supply rooms.

Paul Levy said...

Putting aside the salary question, which I have addressed for me personally on other blog posts, your comment, Keith, is really disrespectful of the people who work in hospitals. This isn't about getting "underlings" to do something. It is about applying principles of process improvement that have been used in other industries in hospital settings. One of the big problems in this field is that they have not been used, notwithstanding the advantages for both workers and patients. It takes commitment, training, and support to make it happen. Once it gets going, though, it is a powerful and satisfying thing for all involved.

Engineer on Medicare said...

Re: Keith
Important elements of process improvements are the concepts of continuous improvement, maintaining process quality, and applying elements of successful innovations to other parts of the enterprise. Applying those concepts to the example related in this thread, one would expect to see the changes sustained and improved by those who have pride in the accomplishment with resistance to "change for the sake of change", and application of the improvement to other elements of the enterprise.

Alice Lee said...

To Doug and Anonymous,
The team's prework began 6 weeks prior to the actual physical transformation of the 2 MICU supply rooms. One major prework focus was on employee involvement and engagement so basic Lean training was conducted for MICU staff. Kristin Russell, the MICU nurse manager, communicated before, during and continues now, after the work to ensure all are in the loop with the intent and results. In addition, all staff were asked for their input on key decisions so everyone in the MICUs were a part of this improvement effort. The idea to work on the MICU supply rooms originated from one of the critical care doctors and was wholeheartedly supported by the MICU team so there was strong interest from the outset to make the improvements and sustain them.

These are the 8th and 9th inpatient supply rooms transformed using Lean 5S principles. We have learned a great deal from each one and continuously improve the improvement delivery process. The manager of each unit's supply room and the distribution manager own the process and work together to address issues (e.g. overages, stock outs) to continuously improve the supply rooms. Everyone knows the supply rooms will need to be continuously tweaked as needs change so standardized procedures for additions, deletions and par level changes are being finalized. There is also a feedback board in the supply rooms for staff to continue to make suggestions.

Anonymous said...

What about the Finard MICU??

Anonymous said...

Alice;

"...standardized procedures for additions, deletions and par level changes are being finalized".

That's what I like to hear!

Keith:

The CEO wouldn't be involved in getting the "underlings" to change the supply room, but he would conceivably be either the one with the idea to use Lean throughout the hospital, or the one to convene his "underlings" to arrive at the idea of systemic (hospital-wide) process improvement themselves. In a book I am reading (recommended by Paul and others), it's called being the "organizational architect."

Whether or not this is worth 1.5 million in a nonprofit hospital (your number, not mine), or considerably more in larger "non-profit" systems such as University of Pittsburgh, is another discussion. But I don't think Bill McGuire was worth 30+ billion at United Health, that's for darn sure.

nonlocal MD

Keith said...

Paul,

I thnk you are reacting in a rather defensive posture to my statement. I do not see the term underlings as particularly offensive and certainly none was intended. I apolize if I offended any of your employees.

I do see the idea that hospital CEOs and apparantly their boards of directors find that those in your positions walk on water and are irreplaceable, and thus demand such high compensation in respect to those "underlings". Why else would such a wide salary differnential exist? This in itself might be considered disrespectful to think you can employ people at one 1/100th of the salary of the CEO, and I would challenge you to ask your employees which they consider more disrespectful; my underling comment or the high differential in compensation that has developed between management and employees.

As to the development of efficiency process, what is there not to like? I only wish someone had arranged the supplies so that I wouldn't need to be searching for the items I need at 1 in the mornng.

Paul Levy said...

No, Keith, I am not being defensive, nor was I responding to your use of the term underling, although I don't think it is a very nice term. I thought you were being disrespectiful about the very important and legitimate role of the staff in making these operational improvements.

As to the salary issue, I have dealt with it a post long ago, but that's really not the issue here. See here: http://runningahospital.blogspot.com/2007/01/do-i-get-paid-too-much.html

Doug Bryan said...

Alice,
Thanks for the reply.
I hope to learn more about BIDMC's progress down the path toward "Easier, Better, Faster, Cheaper."
Thanks, Doug

Keith said...

Once again, I will throw mself on the mercy of the court and apologize for my disrespectful infraction.

I read your prior post regarding compensation and I did read it long ago when you first posted it. It is all too convenient to claim "hey this is what the board decided to pay me".

Amongst all the egregious causes of increases in health care costs, one of the most pervasivly perverse is the development of highly compensated managers of health care organizations that have been driven more by profit than service to the community, especially in the non profit sector. And lets face it; your board undoubtedly consists of several high net worth members which are managers or CEOs or their own organizations. It is a preaching to the choir type phenomena to expect that these boards will pay a less than outsized salary since to do so diminishes their own inflated self worth. When boards of directors are truly made up of community representation that is not selected on their ability to contribute a new wing to the hospital, then I will buy the argument "they forced me to take all that money".

You, I would maintain, dishonor your fellow employees by draining needed resources from the health care system and expecting them to do increasingly more difficult jobs on the front line while the back office guys fatten up their wallets. Lets keep in mind one measure of a non profits effectiveness is the ratio of income devoted to producing its prooduct to its administrative costs. It gets increasingly difficult to do this with "health care managers" sucking larger amounts of money out of the system over the past several years, whether it occurs at hospitals, pharmaceutical companies, or health insurance companies.

When you ask your community, not your board of directors, if this level of compensation is reasonable and get an affirmative answer, then I will have more respect for indiviuals in your position. A board of generaly rich old white guys would not be considered very representative of the community (haven't looked at your board composition, but I will bet this describes 80-90% of your board).

Paul Levy said...

You guess wrong, Keith, about our board. You insist on insulting people you don't even know with comments like "inflated self worth," when in fact these are extremely dedicated people who devote hours of their lives without compensation to helping the hospital do as good a job as possible for the community. Your racial, class, and age stereotypes are equally distateful.

You also guess wrong about what motivates me and our hospital, with regard to service in the community.

This is enough of this type of conversation on this post, which actually had to do with well intentioned people working together in a creative way for the benefit of the staff and the patients.

Anonymous said...

Not to prolong a discussion which Paul wishes to end, but I do think the above comments epitomize the increasing rancor and resentment which characterize the current discussion of health care reform. It is beginning to resemble class warfare to some extent.
Keith I am afraid that your message, which has its validity, was lost in the delivery, which highly resembles that of the congressman who shouted "You lie!" at the President during his speech last night. One is instantly diverted from what statement prompted that shout, to the fact of the profound disrespect of the shout itself.
That said, I do think there is validity in a general discussion of the way money has permeated health care to an alarming degree.
I myself made 4 times what I expected to make during my professional career as a hospital-based physician, and frankly could only justify it by pointing to all the "less useful" people making even more money, like Wall Street, lawyers, etc. Thus do perspectives become distorted.
It all comes back to why people enter health care as a profession in the first place, and who would enter it if the profit motive were removed. Some day, we will find outm either intentionally or accidentally - because our current course is non sustainable.

nonlocal MD

Mark Graban said...

The continuing politicization of healthcare (and the partisan rancor that's accelerating) can't be a good trend. When even an innocuous post about some nice process improvements (which will save cost AND free up staff time to provide better patient care -- better quality), it turns into a class-envy discussion (thanks, Keith). Sad.

Keith - what have you done to improve a process or make something better in your world? I'm just asking. I'd love for you to share.

Neloofar said...

Do you offer an administrative fellowship at your hospital?

If so, I would like to apply. I have done my research, and feel it will be a great place to learn. I have also read a lot of Dr Gawande's work.

Thank you!

Keith (hes back!) said...

Mark,

First off, there is no class envy issue here. What is at issue is proper use of resources and whether excessive executive ocmpensation is a wise use of health care dollars. Not whether Mr. Levy make more money than you or I make.

I would say that I am proud of my service to medicine as a primary care doc who attempts to spend time with my patients and do the things that should be expected in our profession.

In terms of process improvement, I belong to a group of private practitioners who are attempting to design a health care system outside of our major admitting hosptital which has done everything to build themselves into a tertiary/highly specialized hospital because that is where the money is in medicine. Meanwhile, we beg for resources to more effectively run our entry level practices to more efficiently mangage costs, but alas, saving money in health care is not a function that is currently rewarded.

As to other things I am currently involved in, I am an active board member of an organization called Globmed (www.Globmed.org) which is a student run organization with several chapters on college campuses that endeavor to improve health care in impoverished countries. It is the passion of these young students for social justice, here and abroad, that makes me so angry when I see people under the guise of "management" with inflated egos sap huge amounts of resources from actual health care in this country. It is even worse when I see the waste that occurs here in our health care system with the slick marketing of health care in comparison to those countries where we have active projects.

I travel regularly to Guatemala on a Rotary sponsored mission to provide water filtration systems for the Mayan community and have worked closely with an organization called Ak Tenamit that has done loads to improve the lives of people in that region of Guatemala.

I, as a primary care doc, am happy with my level of compensation although I work 60 plus hours a week. I don't understand why everyone else feels like they should get rich off the unfortunate circumstances of patients, and that the more removed the decision makers are from actual patient care, the less they are confronted by the realities of what financial burdens and suffering their high tech, high cost systems are creating.

And Paul, you do what every Manager does when it comes to accounting for their high level of compensation. Claiming I am wrong is not a response. And tell me what community representation exists on your board that truly represents those not in the 6 figure category? If I am wrong, prove it rather than disparaging the messenger. You have the information; I don't. You Mr Levy, do not need to take such a high salary just because your board wants to give it to you. Why not give it back and hire more nurses instead? I figure you could do well to add 50 nurses to your staff for half your salary to put this in perspective. Better yet, since the compensation level you obtain is equal to 100 nurses, lets have you let go 100 nurses and assume their job! What better way to earn your true salary.

Paul Levy said...

Keith,

First you acuse my board of being "rich old white guys", and then when I say you are wrong, you ask me to provide documentation of their wealth, age, and race. Please. This is not a place for cross-examination. You intentionally used that characterization in a sterotypical intent to denigrate their good intentions. If you want to know who they are, you can go to our Form 990 and do your own research.

But let's say, for the sake of argument, that they were "rich old white guys." It would still be just plain wrong to assume that those characteristics have any relationship to their degree of public-spiritedness or to the degree they exercise appropriate due diligence in setting executive salaries.

To your underlying question as to why I accept the salary offered to me, it is because I believe it to be an appropriate salary for this job. It is well within range of others in these kind of positions -- the standard that is established by law in this country. What I chose to do with my salary, philanthropically or otherwise, is my personal business. I might, for example, feel that it is more than I need personally for me and my family and therefore donate it to charitable causes, including this very hospital, public health, medicine, and the like -- maybe even in Guatemala! Or I might use it for completely selfish purposes. I don't intend to tell you or anyone else.

Given the language you have used in early comments, I am skeptical when you say you have no intent to make this an issue of class warfare or morality. I personally don't buy into that approach, and I also didn't when I earned a lot less in public service jobs during much of my career. We each make our own career decisions, and it is just not right to judge other people's intentions or morals by how much money they make. Nor, I suggest, is a person inherently more or less moral because s/he chooses to earn less.

By the way, nice work in your chosen profession and in your charitable causes! It sounds very admirable, but then, again, who am I to judge?

Mark Graban said...

I can hear sound on the first and third videos, but not the second... is that just me?

Paul Levy said...

Sorry, Mark, we have, er, a quality control issue in that video!

Anonymous said...

Oh, but now I understand Keith much better - it's the classic "docs vs. suits" issue. Having had to straddle the middle as a hospital-based doc, I can see both sides, although I admit to having thought along his lines as far as my own hospital system was concerned. Perhaps you want to address your remarks to your own hospital CEO and Board, Keith. My personal experience with Paul is that, although tending toward somewhat combative (:), he is far more concerned about advancing clinical quality and patient safety in his hospital than any other suit I have encountered.

nonlocal MD

Anonymous said...

Oh and just for interest, here's an article on what various bigwigs in my area make (scroll down to the last paragraph for hospitals and docs). The one that got me was our Children's Hospital (2.2 mil), which I believe is less than a 200 bed hospital and is constantly appealing for funds "for the children." Choke.

http://www.washingtonian.com/print/articles/11/155/12389.html

nonlocal MD

Keith said...

Paul,

It is certainly within anyones right to question how money is used when it is tax exempt as your institution is. If you were a for profit institution then it is the end of discussion, but when you claim to be "tax exempt", you open up to public scrutiny.

I too often see boards selected on the basis of how much they contibute to the hospital and not on what they can do to benefit the community they presumably serve. I don't know your particular motivation or your board make up, but I will tell you that most non profit institutions construct their boards on the basis of contributions to the hospital rather than true board oversight. You becocme the easy target by having enough cahounas to post a blog and put your thoughts out there, to which I commend you. Most hospital CEOs hide away spending most of their time kissing the behinds of their wealthy board. I blame other semi worhtless CEOs who make enormous sums of money, some of which work hard to make our lives miserable as health care providers, for making us all feel like we are underpaid. Why does that jerk make 20 mil a year for runinng an insurance company when I only make 1 mil for the diffcult job of mangaing a hospital? It is all ludicrous stuff, and I would hope to return the art of medicine back to a focus on patient care that frankly does not make one outrageously wealthy. But as long as management sees itself as so essential to running a hospital as measured by its outsized salary (I would use CEO to nurse salary ratio as the best measure) it will result in disdain from those who try to do best for their patients for much less compensation. It is not that we demand more, but that we ask that you who control the cash use the funds wisely to provide what is needed in health care; to take care of those most in need who live on a fraction of what you or I make. When we accomplish this, then it will be appropriate to fatten our own wallets.

Paul Levy said...

Thank you very much, Keith. I truly understand the sentiments you express, and I certainly don't doubt that some people fit into the categories you describe. On the other hand, most CEOs I have met in hospital roles are extremely dedicated to the public good and are very fine managers who could actually make more money in other fields. Part of attracting them to their current jobs is to offer the kinds of salaries you see. One could argue, of course, that there would be other qualified people willing to do the job for less, and that may be so. But -- in the US anyway -- one measure of qualification is experience running other large organizations; and so the pool from which boards are likely to search for CEOs tends to be people who are paid more in the first place. Perhaps that is an inequitable or self-limiting cycle, but it is the real world of executive searches in this country.

Where you and I might agree even more is about the degree to which CEOs are actually held accountable for their job performance. I think that boards often neglect this part of their fiduciary responsibility. It is one thing to pay someone a lot if they are doing the job well. It is another to not measure that performance. From what I have seen, hospital boards often neglect this responsibility. (By the way, ditto for many corporate boards, too.)

lymie said...

I don't think the videos show what you think they show. In the after video Tim collects only 4 items, in the before video he collects 8. In both he wanders around using a mental check list to get what is needed, why is this not standard? Could there be packs with all that is needed? Should a list be posted on the wall?

Alice Lee said...

To Mark Graban: actually, we intentionally took the sound off of video #2 because we showed #1 and #2 simultaneously to show the differences and Tim is essentially saying the same thing in both videos. Sorry for the confusion!

Anonymous said...

Now that we are calmly discussing the issues, I would like to broaden Keith's argument beyond just the CEO. (I believe he also alluded to this in an earlier comment.) One often uses the yardstick of "administrative costs" as a percentage to evaluate the function of charities, as well as for health insurance companies, Medicare, etc.
When one applies this yardstick to the average hospital, I think Keith may be correct in saying that administrative costs(much of which is salary cost) probably occupy too large a percentage of the total costs of delivering care to patients. By "administration" I include such functions as utilization review, which didn't exist when I first started practicing.
In all fairness, some of this extra administration was added as a consequence of government regulations or accreditation-related expenses, like the bureaucracy needed to pass your JC inspections, for instance.
However, I noted in my own hospital system that periodically the VP position would proliferate - with assistant VP's, associate VP's, senior VP's, executive VP's, etc. being added at an alarming rate over 5-8 years. Then when money got tight, all these VP's would be purged in one chop, and the system would go back to what I would consider "normal." Then, over another 5-10 years, they were gradually added back again.
So if these people were so easily expended, what indispensable functions critical to patient care were they performing which could be so quickly jettisoned?

It's not just the CEO, in my opinion.

nonlocal

Paul Levy said...

Human nature: All organizations have a tendency to add people as workload grows, without figuring out what or who they could do without. Then, when financial crises arrive, they pare back.

But, with great respect to my two MD correspondents here, I will say that very often the medical staff have little or no idea of the personnel needs of complicated places like hospitals. It is often easy to blame clinical or budgetary woes on "the overhead", especially when you have had no experience in administration. I'll give you and example in a future post, and you can be the judge.

In our place, we monitor all employment -- clinical and non -- very closely all the time. Likewise, we are constantly reviewing our management structure to reduce layers and to make sure that we are operating reasonably efficiently.

Anonymous said...

Aha! Looking forward to learning from your future post(s), since to me that's what "running a hospital" is here to teach me.

nonlocal