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Process Redesign for Health Care Using Lean Thinking: A Guide for Improving Patient Flow and the Quality and Safety of Care by David I Ben-Tovin

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Lean Thinking is increasingly migrating from manufacturing to the services sector. There is a clear distinction between the product and the customer, and Lean Thinking helps streamline production processes and make delivery of the product to the customer faster and more predictable. In Health Care, the customer is the “raw material.” The owner of a new car is not present while minerals are mined, smelted, refined, and turned into sheets of metal that are delivered to a car maker. By contrast, the patient is a sentient being who is present, observing and experiencing at every stage of the transformation of his or her raw material, except, in the case of some patients, for a brief period of oblivion during an operation. Authorization nor permission can not be taken for granted in healthcare, both have to be built step by step.

What peoples want from a shop and health care are similar

◾ A pleasant environment

◾ Prompt service

◾ Clear information

◾ Respectful treatment

◾ Choice

◾ A product that works

◾ Value for money

In health patients also crucially want a plan – patients make it clear that they want Health Care workers to make a plan and then discuss it with them. It however, may seem for the patient that they are the only person who knows the outline of the plan, and what is supposed to be happening when.

If you are too sick to look after yourself, and you do not have a family member or friend keeping track of the plan and advocating for you, look out.

So how do you know what do the patient’s want and value – the only way to be certain that your customers value what you make is to ask them.

Looking at workload in hospitals

80% of all requests were straightforward;

10% involved a small amount of extra work,

10% were very complicated and took half a day or more to resolve.

Building on this requests could first be divided into “short” (number of operations involved) and “long” (number of operations involved) value streams. Once divided up, the specifics could then be taken into account.

It is worth thinking about journeys through healthcare to critically analyse it and attempt to make it more efficient. The more complicated the overall production process, the harder it is for the different groups that are involved to see themselves as part of the whole. If the participants cannot see how their steps link up with processes further down the line, and what impact poor coordination has on the delivery of care, it will be hard to get the whole process working smoothly.

The journey through healthcare doesn’t just have to apply to patients it can be used to analyse items such as stocking and delivery of towels and look for ways this could be improved.

Waiting and Queuing – there is a distinction. Waiting implies waiting without order unlike queuing which is waiting in an order.

Overproduction in Health Care may be considered in particular when doctors get paid for each procedure they do, they may be encouraged to perform invasive investigations or procedures before they are clinically necessary. For example knee arthroscopy to investigate pain in the knee that has only just occurred.

In many hospitals, 20–30% of patients are cared for as outliers from their home wards, which means the team responsible for their care must travel to look after them which causes resultant waste of motion.

Describes a concept in hospitals as “pull” – this is wards and teams with particular skills and interests going to the Emergency Department and other areas of the hospital, pulling the patients that they need to fill their beds as vacancies arise. This is potentially more efficient.

Be aware of your sphere of influence, you likely will need to involve others to make change.

When attempting to solve one problem someone may respond but what about a different issue. An example would be medication for discharge dispensed late in day then why was the discharge not done earlier. Therefore be sure to have a clear scope of a project and involve key people who have appropriate sphere of influence.

Process Redesign for Health Care assumes that competent practitioners will be well versed in the advances in their field. The intent of Process Redesign for Health Care is not to challenge that competency but to provide a method by which those practitioners will be enabled to practice their skills in the most efficient and effective way possible. Scoping defines where to look and the Big Picture Map creates a simplified model of the Health Care processes involved.

Process Mapping and big Picture Mapping are not simply about the engineer or redesigner understanding the process. It is a collective activity in which a map is created by direct and public interaction with the participants, who describe to each other the roles that they play. Therefore for Big Picture Mapping session to be successful, the right people need to be in the room. There is no point trying to map out a process if the senior clinical stakeholders, be they doctors, nurses, or allied health practitioners, are not present. They are key members of the social system involved and need to be involved in the process. Equally the clerical and administrative staff that do the greeting and appointing functions are required to be present.

An easy way to perform root cause analysis is to ask “Why?” five times

Process Mapping- consider following people with a clip board or ask them to track the time they spend on certain tasks themselves.

Key performance indicators (KPIs) tend to be numerous, so look pay attention to ones for which you are an outlier. When interpreting KPIs remember the role of chance, by chance 1 in 20 times that could explain an outlier on a 95% confidence interval.

In quality improvement ‘wastage’ is time spent looking for things or people. Cut wastage down then allocate tasks to use this time better.

Plan Do Study Act (PDSA) cycle

When it comes to planning care typically planned care is scheduled 24 hours or more ahead and can be anticipated versus unplanned care which occurs in less than 24 hours. Work can be divided into short versus longer time scales. Time isn’t the only factor to consider, the skill involved for both long and short work is important. Generally a task is best done by people who are experienced in that work. Short is not simple.

Flow: Once a process has been defined, and the series of steps involved are clear, the workgroup involved can turn its attention to improving the flow of work through the process. Improving flow lies at the heart of Lean Thinking and is central to Process Redesign work.

First, whatever is being worked on has to leave each step fit for processing at the next step. Otherwise, the overall process is hopelessly inefficient. Second, the pace of production at each step needs to take into account capacity at the following step. Otherwise, delays occur as the excess product of one step has to be stored before it can be used by a slower step. Uneven flow can also lead to unused capacity, as machines and people wait excessive periods of time for material to be produced by earlier steps.

In Process Redesign, the general principle is to organize work processes around predictable patterns of demand, rather than to suit the preferences of the staff in an institution. This strategy influences many aspects of redesign, especially the need to reduce batching.

Human beings have a natural tendency to see the world from their own point of view, and to value their time and convenience ahead of the time and convenience of others. Health Care, with its relative imbalance of power and knowledge between patient and care provider, is particularly prone to this tendency. It is only too easy to place a high value on the time and convenience of medical and nursing staff, and to put a low-to-zero value on patients’ time and convenience. Splitting an on call take for medicine or redesigning fracture clinics to make the workload more consistent are mentioned as examples that have been successful due to process redesign.

A problem occurs; an error is made the solution is a checking step is added. This checking step may in fact be unnecessary once the problem has been rectified, but it is much harder to stop an extra process than to add one, even if the problem that prompted it has been sorted out. Health Care is filled with add-on, just-in-case processes, however, these add-on steps are self-defeating. If every step has an error rate of only 5%, and a process has 10 steps, by the time the process has been completed, the likelihood of an error somewhere in the process has risen to at least 50%. A vicious circle sets in. The healthcare process is complicated, therefore is prone to error. Because it is prone to error, extra checking and just-in-case steps are added.

‘5S’ is a translation of a set of Japanese words, seiri, seiton, seiso, seiketsu, and shitsuke (translated as sort, shine, set in order, standardize, and sustain)

Sort – take everything out. Sort into things to throw away, things to keep, and things to review

Shine – take the opportunity to clean up

Set in order – develop a structure for access and storage based on use patterns

Standardize – formalize the structure, so that the storage and retrieval solutions become standard practice

Sustain – define the “ownership” of the storage area and assign responsibility for its maintenance

“Visual management” is the term commonly used to describe the range of strategies that use visual systems to support process management and process control. The basic principles behind many of the visual management strategies that work go back to the insights of an important figure in perceptual psychology, J.J. Gibson (1979). Gibson talked about environmental affordances, which he defined as “all actions latent in the environment,” but more easily understood as those features of the environment that instruct you.

The designer Donald Norman (2013) developed the concept further by discussing how objects can be well designed so that they clearly suggest how a person has to interact with them. Some designed objects have “good” (i.e. easily identifiable) affordances, telling you how to hold them and how to use them, while others need further work on their affordances. When we see a door with a handle, we instinctively assume that we pull to open it. When we see a door with a flat plate, we instinctively assume we push to open it.

In general health care hasn’t been designed well from the ‘affordance’ point of view but there is potential. For example having clear signs providing useful information such as symbols and commands, or floor markings to provide the ability to readily see who arrived first. The ideal visual management system is simple, easy to understand, and democratic. It is a signalling system that all users, from senior consultants to junior clerical officers, should be able to understand and act on appropriately. Visual management systems that work are systems that have been designed and developed by the people who use them. Given the opportunity, the ingenuity of the health workforce is boundless.

Queuing Theory and Operational Research concerns how different kinds of queue disciplines will affect the length of time individuals, or groups of individuals, will spend in queues. Not all queues are equal. Health Care commonly involves short-term queues and long-term queues. Short-term queues are the queues that form within hospitals, in Emergency Departments, X-ray services, out-patient clinics, and hospital wards. Long-term queues are made up from patients waiting, in their own homes or other facilities, to be called into the hospital to begin to receive the definitive care they need. Long-term queues are usually known as waiting lists.

Short-term queues are common in unplanned work. In unplanned work, the patient presents directly to the service station. Even when the service station is very busy, the patients cannot be sent home unassessed, so a queue forms that has to be worked through. First in first out (FIFO) is simple and equitable. It minimizes the overall amount of time that individuals wait in a queue, provided that no one gets moved out of order to the head of the queue.

A buffer slot is a designated clinic appointment or slot that is kept free. Receptionists are not allowed to book a patient into a buffer slot. A busy clinic may have more than one buffer slot spread over a clinic session. Patients are not necessarily seen in the buffer slot appointment. That is not what the buffer is for. The unplanned arrival is slotted in whenever it is convenient. The buffer slot is there to contain the disruption caused by having to fit in an emergency patient.

As a rule of thumb, if the intrusions represent more than 10% of the workload of the clinic, then mixing unplanned and planned work will not work. In such cases, it is better to create a separate work stream for the unplanned work. That separate work stream can be in a different area of the hospital or be provided by a different team. When that is not possible, a common strategy is to “bundle up” the unplanned jobs and put them at the end of the designated clinic time and then see the patients on a FIFO basis.

An alternative strategy for making clinics is to determine the shortest usual time for a consultation. Then divide the whole clinic period up into equal time slots using the shortest time as the slot time. Each clinician who is running the clinic is informed that they can have as many, or as few, slots as you need for each patient. Look at your clinic list, and nominate the number of slots you need for each patient. And after a consultation, if follow up is required please nominate the number of slots you need for that patient.

If a clinician with a full clinic order book misses a clinic because of ill-health, a domestic crisis, an unplanned emergency, or simply fails to tell the receptionist about a planned holiday until the week before going on leave, the booked patients do not go away. The clinic capacity for that day is lost forever but the demand moves forward. Now a group of patients have to be slotted into a system that has no spare slots, because every slot is taken up months or years in advance. Hours of time are taken up trying to squeeze patients into fully booked clinics. The root cause of the chaos is failure to apply lean thinking.

If you follow lean thinking principle number one, “Specify value from the viewpoint of the end-customer.” What a customer needs is timely, prompt, and predictable care. It is the provider, not the patient, who needs the full appointment book. How can the provider with a busy practice provide a good service that also values the patient’s time? Partial or patient-centred booking is suggested, this is a process whereby clinics are only booked for a limited time in advance. A month is a good period.

Patients are told that their follow up will be in a month, 3 months, 6 months, 1 year, or whatever time ahead is appropriate. But they are not given a fixed date. They are told that they will be offered a specific appointment closer (2–3 weeks works well) to the time. They can then take up that appointment or an alternative can be arranged.

To implement a partial booking system that works relies on:

Getting patients’ contact details right, this can be useful to improve the accuracy of patients records

A notification system that tells the booking clerk when patients are due to be seen

The ability to get in touch with people to give them an appointment when the appointment is due

Partial booking is administratively more demanding than just giving a patient an appointment for a fixed period such as weeks or months in advance. It does however minimise the very complicated shuffling of appointments, because the clinic slots are not taken up months in advance. Partial booking also minimises do not attends, so clinics can run smoothly on the day.

Process Redesigners dislike prioritization. Process Redesigners can count to two: (1) life or death (2) everyone else. Or maybe to three: (1) life and death, (2) see very soon, and (3) everyone else. But, not more than three. The reasons why Process Redesigners dislike prioritization go back to a combination of common sense and Little’s Law.

Common sense tells us that our capacity to predict the future in relation to the unfolding of illness is limited. Little’s Law states that in the long term, the average number of customers in a stable system is equal to the long-term average effective arrival rate, multiplied by the average time a customer spends in the system. Despite their apparent unpredictability, Emergency Departments’ short-term queues can be considered to be stable systems, because the underlying characteristics of times and numbers of patient arrivals vary little from day to day. And long-term queues, or waiting lists, are by their nature stable systems with planned exits and defined internal structures.

The general point is that prioritization in any service enables a small number of patients to be seen relatively quickly. But one person’s priority is another person’s wait. When someone says, “this is not right, we must do something about the next available patient group”, the first thing is to do go through and ask every next available patient on the waiting list (assuming you have their up to date contact details) if they still need the service they have never in practice been offered. Commonly, of those that have survived, a substantial percentage have either recovered or received the service elsewhere. After that, the best thing to do before simplifying the prioritizing process is go back to the beginning and look at the capacity of the system and the demand the arrivals make on it.

Erlang Variables λ = the average number of jobs arriving per hour. Using per hour as the common denominator (it could be per minute or per day; what matters is that it is the same time interval as the arrival rate), the service rate (μ) is the average number of jobs that the existing resources are able to service per hour if every available second was used for processing. By observation, it is possible to identify how long a job takes, and use that to calculate the number that is possible to complete per hour. μ = the average number of jobs that can be completed per hour. P (the utilization rate) = λ/μ. If utilization rates are well below 85%, there is every likelihood that driving out the waste will ensure that short-term, and long-term, queues can be reduced or eliminated, allowing the claim for additional resources to be reassessed.

Book provides an example of CT scanner use, finding radiologist to administer contrast, radiographer going on breaks at the same time where addressed, having a rota so easier to find the radiologist who administers IV contrast and shuffling breaks so there is always a radiographer working can reduces waste.

If however, you find that utilization rates are above 85 % it is much harder to become more efficient. Instead think are there small improvements that can save minutes? Can some steps be eliminated, or merged, or simplified? This is challenging work, and it will call on the flexibility and ingenuity of all the staff involved. It is also very important to acknowledge that at utilization rates of 85% and over, queues start to become inevitable with even small increases in the number of arrivals.

If working to full capacity all buffers are removed. Each patient is unique so time not easily predictable, also each staff member has variable skills so queues become almost certain.

Keep it simple; separate value streams; challenge prioritizing wherever you see it. Immediate threats to life and limb, and then other very urgent problems, have to be prioritized, but try to leave it at that and see the rest of the patients in order of registration or arrival. Acknowledge the extraordinary skill and ingenuity shop-floor staff display as they keep the work going. Try not to take them for granted. And when you really do not know what to do, try FIFO. It is simple, easy to explain, and easy to manage.

FIFO definitely saves lives. The people who do not like it will make their views known anyway, but it may turn out that they are a small minority, and their views should not be allowed to derail the changes. Questions such as, “Are things different from how they used to be?,” “Is the work easier or harder to do?,” “Are patients getting a better service?,” and “Should we go on with the new way of working?” are simple questions, but the answers provide very important information. Although clearly – there is no point asking the people what they think if you are not prepared to listen to their views.

For process Redesign widely publicise this to the whole of the trust and relevant stakeholders so they know you aims.

Short is short because of the limited number of process steps. Short work is certainly not simple work, and the Emergency Department work reinforced the importance of using the concepts of short and long, rather than simple and complex. “it was not up to the hospital to judge patient’s motives in presenting to the Emergency Department, and decide their worthiness for care. Our task was to provide safe care to everyone who sought it.” A fairer process had been developed and implemented, and that process of streaming, as it is known, has become the norm in many hospitals throughout Australia. They divided up work into may go home, likely admitted did this FIFO unless life or limb threatening illness or resus.

The book mentions a digital solution, the problem was lots of wastage, bleeping a busy person, then phoning, then not waiting for phone when they phoned back. A concept of an internet based whiteboard was established. Using the EMTB web application that, when a user logs on to it, they have a simple form for “logging a job.” The form is formatted as rows in a table. The user inserts a job, location details, clinical team details, and task details. Time and job number are automatically inserted by the program. Crucially, there is a box the doctors tick when they complete a task. The program that lies behind the task board knows which intern is responsible for the ward and is “on” for the relevant team, as the program has a look up table derived from the existing medical staff electronic rosters. In addition putting all cannula equipment in an easily identified box can help efficiency.

Clear problems with work organization can make it obvious that the primary task was to improve work practices within the existing resources, not to try and turn the clock back or look for additional resources. Process Redesign is not about getting in the way of the technical “how” of work such as how perform a laparoscopic appendectomy, or treat a myocardial infarction, these decisions need to be left to the knowledge worker, and that knowledge workers knowledge work supervisor. If corporate managers or redesigners without the relevant expert knowledge try to tell knowledge workers about the technical aspects of their knowledge work, they quickly lose those people’s cooperation.

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