Lean Work Processes and the Health Care Crisis
A year and a half ago I found myself in an Emergency Room at 5:00 a.m. on a Monday morning with a bad case of bronchitis. As I was resting in an examining room, I noted a nurse coming into the room in which I had been placed. I watched as she approached the cabinets on one side of the room and started opening drawers. She opened one ... and two ... and three ... and finally found what she was looking for, a pair of latex gloves. I was getting bored and decided to do some Lean fact-finding and asked her, "How do you know which drawer the latex gloves are in?" She quickly answered, "I have to open the drawers." Getting more curious, I asked another question, "Are the latex gloves in the same drawer in each of the examining rooms?" She answered in a tone of voice that reflected both a bit of impatience at my nosiness coupled with the belief that she was describing a rational world. Her answer, "No, they're not." I was also struck by the absolute innocence of her response. She seemed to see nothing at all odd about what she had said.
Yet, you and I as "outside" observers of this encounter can, in our mind's eye, "look" at it and say to ourselves, "how irrational." And, of course, what I just described is irrational. But the really important issue is not that you and I can see this behavior as irrational. The heart of the matter is that the nurse didn't. On the contrary, she saw her behavior as normal. Here was an individual who was a well educated, trained, and dedicated health care professional who each day wasted time while engaged in the irrational pursuit of latex gloves hidden in anonymous examining room drawers. Why did it never occur to her to work with her teammates in the ER in a meeting focused on this question: In which drawer in our examining rooms should latex gloves be located? And, after reaching consensus on this question, to agree that: 1) the gloves should be in the same drawer in each of the hospital's fifteen examining rooms, and 2) the drawers should be clearly labeled, "Latex Gloves." But back to the question, "Why didn't these simple steps occur to her?"
I believe the answer has to do with the way the human brain operates. My years of working in a wide variety of work places, helping teams implement Lean work processes have taught me that you and I ... in fact, all human beings ... have the ability to work in highly dysfunctional work spaces and view them as normal. And, as a result, we have little motivation to change these dysfunctional spaces. In fact, we never see the need to quit searching for the latex gloves ... until reality comes crashing in with a loud voice telling us that we've got to become more productive ... that we've got to produce higher quality ... that we've got to cut down on waste ... that we've got to optimize our work processes. And at that point, it's sometimes too late for some organizations. But the lucky ones hear the clarion call in time and act upon it, initiating a serious effort to implement the basic beliefs of Lean manufacturing, coupled with Lean thinking and Lean analytical tools.
As we all know, and as is especially top of mind in today's public discourse, health care in our country costs too much, reaches too few, and harms too many. Here are just a few examples:
- Preventable infections acquired in hospitals cost $4.5 billion dollars per year and contribute to 88,000 deaths - one death every six minutes in the U.S.
- Medication errors alone are estimated to account for over 7,000 deaths annually. This represents about 16 percent more deaths than the number attributable to work-related injuries and is estimated to add $35 billion dollars to the total cost of health care.
- As much as one-third of premium dollars pay for misprescribed medication, unneeded surgery, preventable infections, and other errors.
The vast majority of these performance problems are not caused by bad doctors, nurses, support staff, medication quality, or equipment deficits. On the contrary, the American health care system is populated by some of the best trained professionals in the world using very high quality medications, and having access to state of the art diagnostic equipment. So if it's not training, medications, or equipment that is at fault, what is it?
In a nutshell, and to use the example I described at the beginning of this podcast, the heart of the matter is too much searching for latex gloves. Or to use more sophisticated language, the core issue is the quality of work processes used in health care facilities.
As I just said, to drive higher levels of productivity and quality, many hospitals and other health care facilities across the nation are aggressively implementing productivity improvement processes based upon the philosophy that drives Lean manufacturing as well as the work processes that translate this philosophy into action.
What are the basic beliefs that underlie Lean and are the foundation upon which it success is built? They are that:
- All work processes are imperfect.
- Driving work processes toward perfection must be done by tapping the creativity and knowledge of the individuals who do the work.
- The primary job responsibility of all levels of leadership, from front line supervisors to CEOs, is to serve as catalysts, triggering the creativity of their direct reports and focusing the organization on the relentless pursuit of perfection.
Just as these beliefs, coupled with the tools of Lean Manufacturing such as 5S, Value Stream Mapping, Work Cell Redesign, Pull Production, Continuous Flow, Standardized Work, and others have driven remarkable increases in the productivity of manufacturers; they are also having a very positive impact on health care costs as well as the quality of health care services.
As reported by the health care industry worldwide, here are some examples of the impact of Lean on two critical health care issues - preventable infection rates in hospitals and health care costs.
Regarding preventable infection rates:
- Problem: Preventable infections acquired in hospitals cost $4.5 billion per year and contribute to more than 88,000 deaths - one death every six minutes in the United States.
- Impact of Lean: Reduced patient deaths related to blood stream infections by 95%.
Regarding health care costs:
- Problem: The cost of health care in the United States has been rising at an astronomical rate - it accounts for roughly 16.2% of our nation's Gross Domestic Product, which is among the highest of all industrialized countries. And U.S. health care spending is projected to reach $4.3 trillion dollars in 2017 or 20% of the GDP.
- Impact of Lean: Here are just several examples:
- As reported by Wellmark Blue Cross Blue Shield of Des Moines, the application of Lean work processes drove "documented hard dollar savings of $3.7 million" in one year by finding and identifying non-value-added processes and waste. It also helped Wellmark recoup over $1.7 million in overpayments to physicians and captured over $280,000 in administrative costs.
- Various hospitals have reported productivity gains, each of which impact costs, such as:
- Cost of meals reduced per tray from $1.37 to $1.15
- Saved 133 miles of walking per nurse per year
- Stock levels in Pathology Department reduced by 60%
- Reduced turnaround time for clinical laboratory results by 60% without adding head count or new instrumentation
- Increased surgical revenue by $808,000 annually
Many other productivity and quality of care improvements driven by the focused and tenacious application of Lean thinking and Lean analytical tools could be cited from health care literature.
Let me conclude this webcast with an old, somewhat hackneyed phrase. Achieving these types of improvements is not easy; nor is it "rocket science." What it takes is a health care leadership team that understands that Lean is about changing what employees believe and how they think as much as it is about the tools of Lean. It also takes managers and first-level supervisors with an understanding of Lean processes coupled with the supervisory skills needed to drive the implementation of these processes.
St. Louis Community College has resources that can help health care facilities successfully launch their Lean journey. For example, the College's Lean Leadership Certificate Program is an ideal way to prepare a health care staff to successfully support a transition to Lean processes. I'd like to meet with you to review the ways in which these resources could serve you as your hospital, nursing or assisted living facility works to meet the cost and quality challenges of the 21st Century through the application of Lean thinking and Lean work processes. Call me, George Friesen, at 314-303-0612 and let's schedule a meeting. I hope you've found this podcast to be both interesting and productive. Have a great day!