Embracing Lean, Business Intelligence and Leadership to achieve process improvement in the Pathology laboratory

Cathy Bouwers Communications Associate

The laboratory world is no stranger to change. Be it changes to staff, policies, budgets or processes, many of these changes are due to working with fewer resources. Dealing with these changes can easily distort the bigger picture – dealing with customer needs. Customers are those on the receiving end of laboratory services; patients, physicians, co-workers. When the focus of the work is taken away from the customer experience, the value of the service suffers. Enter the lean experience.

Lean has been used in manufacturing industries since the late 1980s, but it can, and has, been applied to other industries, including health care. The main idea of lean thinking is to maximize customer value while minimizing waste. This concept reorganizes the way of thinking to simplify processes in order to improve the value to customers while using minimal resources.

This concept was embraced by
the pathology laboratories at Grand River Hospital (GRH) and St. Mary’s General Hospital (SMGH) in Kitchener, Ontario. The CSMLS had a chance to speak with Vince D’Mello, Administrative Director, about why and how the laboratories decided to go lean.

CSMLS: How would you describe the lab at Grand River and St. Mary’s prior to implementing lean processes? What made you think a lean approach would be the solution?

D’Mello: In 2010 at Grand River Hospital and St. Mary’s General Hospital it became clearly apparent that the Pathology section was not meeting clinical needs on a consistent basis. In addition, we were experiencing significant backlogs
of cases and the workflow, which
was based on historical professional practices and preferences, was
not structured to meet clinical
needs. The work atmosphere was stressful and cases were constantly being re-prioritized because of the delays and clients calling for their reports. Clearly this model was not sustainable nor was the misleading concept that adding more resources at a time of fiscal restraint would solve the workflow problem and at the same time improve turnaround times (TAT’s).

After careful consideration of several available options it was decided
that undertaking a ‘Lean Study’
would provide the best opportunity for improvement as well as help transform our operational issues to meet clients’ needs. Undertaking lean optimizes workflow, resource utilization, improves staff productivity, operational efficiencies and staff and client satisfaction.

CSMLS: Can you describe how you applied lean to your lab?

D’Mello: In our case, we used it as an opportunity to improve TAT’s, eliminate backlogs, and influence the adoption of lean thinking as a cultural change initiative, within the department.

The lean journey undertaken in the Pathology section was the first formal lean study at both GRH and SMGH. We used an external facilitator, Mike Boucher from Lean Advisors to help us learn, plan, implement and improve our knowledge and skills related to lean principles and work flow design.

CSMLS: What were some of the challenges you faced in the early implementation phases of the process?

D’Mello: At the outset of our
 lean journey we understood that the changes would require transparency, focused communications, teamwork and a collaborative mindset to achieve success. We created and agreed on a set of change management principles, which included a zero tolerance
for blame or shame tactics, and a commitment to evidence-based decisions that were patient centered. To help staff participate in making 
the improvements, we provided dedicated participation time. We selected staff members to serve on teams that supported our vision
and were willing to follow the lean process. We conducted value stream mapping of our current state, which enabled us to build the future vision, and reconfigured workflow model. This in turn enabled us to identify and subsequently eliminate non value- added steps or processes which led to improved workflow, staff productivity, operational efficiencies and TAT’s.

Implementing change is never easy. In our case we were successful as the vision was engaging, there was strong leadership support, many front-line staff championed the effort, and we maintained our change management principles throughout the study.

CSMLS: What were the key changes implemented?

D’Mello: In order to achieve a balanced workflow model, we needed to make significant changes in the pre-analytical, analytical and post- analytical phases of the operation.

In the pre-analytical phase the key changes implemented were the elimination of pre-assignment of cases to pathologists. In addition we are now using clerical staff to accession and order entry cases as opposed to using technical laboratory assistants. In the analytical phase a key change was the creation of a work cell, which combined embedding, cutting and staining procedures. We also reduced the need to re-screen gyne cases by 30 per cent which freed up technical staff for other tasks. The most significant changes in the post-analytical phase was the creation of a centralized supermarket where pathologists access and pull cases for sign-out based on priority, the day of the week and FIFO (first in first out) principles. The supermarket model uses a pull versus push workflow distribution model that is based on clients/patients’ needs and is shown in below.

The supermarket

CSMLS: What has helped to sustain the improvements and successes?

D’Mello: It is generally accepted that it is far more challenging to sustain improvements compared to initially implementing the changes. A number of strategies, when combined, have enabled success. For example, eliminating the silo culture between various professional groups, encouraging teamwork, and creating rapid response teams, to address in a proactive manner —workflow problems and backlogs when the dashboard indicators are in the
yellow or red zone. The use of visual controls and dashboards, both manual and electronic, are key enablers in sustaining improvements.

CSMLS: How did your laboratory staff react to the changes that were made?

D’Mello: The best way to answer this question is to review the results
of the staff engagement survey that was conducted three months after going live with the new lean workflow model. Table 1 shows highlights of the staff survey which received a 60 per cent response rate.

Implementing the new workflow model has had a positive impact on service delivery, job satisfaction, improved productivity, TATs and has led to a significant reduction of operational bottlenecks and case backlogs.

CSMLS: What were the results of implementing lean?

D’Mello: Our definition of TAT (turnaround time) is from the time the specimen is accessioned to the time that the case is signed out.

Table 1

After developing our future state vision and completing proof of concept testing, we set ourselves a TAT stretch goal of 90 per cent of all case types (large biopsies, routine, gyne and non-gyne cytology) to be signed out in five working days. The proof of concept studies validated that this was a practical and realistic goal that is aligned with College of American Pathologists (CAP) standards, Cancer Care Ontario TAT goals and our clients/patients’ needs.

Success is typically measured in incremental steps and compared to pre-lean baseline measures. The team believed strongly in the philosophy of ‘what gets measured gets improved’. It is important to communicate performance targets widely and regularly to support evidence process improvements that may be indicated to meet stretch goals.

Table 2, describes our TAT performance.

Another departmental stretch goal was to reduce backlogs to no more than two days. We have experienced improvements in most areas. The grossing of large cases in FIFO (first in first out) continues to be a challenge and an opportunity for improvement.

CSMLS: What advice would you give to another laboratory considering implementing lean?

D’Mello: From our experiences the magnitude and scope of change was complex, we believe the following elements enabled our team to achieve and more importantly sustain success.

• Strong and effective leadership, both formal and situational
• Engaging vision that focuses on the patient
• Maximizing staff strengths
• Clear accountability framework
• Allocating project management resources
• Team Kaizen (improvement opportunities) charters with realistic goals/objectives and timeframes
• Business Intelligence applications, visual controls and performance dashboards
• Skillfully managing fears, setbacks and skeptics in a respectful and collaborative manner
• Transparency with communications and problem solving
• Providing staff education and training
• Empowering front-line staff to champion changes through teamwork and professionalism

I believe that by adopting an open and flexible mindset with the patients’ interests in mind helps achieve success. Improvements and changes that are evidence based are important for staff engagement. Avoid analysis paralysis and chasing the perfect solution. Keep the staff informed about progress and skillfully manage fears, setbacks and skeptics.

Acknowledgements:

Vince D’Mello would like to thank the
staff at Grand River Hospital and St. Mary’s General Hospital for their invaluable help, support and dedication with this study as well as Mike Boucher from Lean Advisors and Tim Kuruvilla from Viewics Inc. for their assistance with the study.

Lean is a journey of continuous improvement and throughout their journey, Lean Advisors has introduced Lean thinking and applications at the day to day operational level through Enterprise Value Stream Mapping as well as at the strategic, business planning level through Hoshin Planning. That enterprise level of commitment is delivering results in terms of improved efficiency, productivity, staff engagement and most importantly with increased client satisfaction.

Here is their story:

In 2008, The Saskatchewan Assessment Management Agency (SAMA) adopted the Lean business process improvement strategy.  SAMA is responsible for the governance of the overall assessment system in Saskatchewan, and the provision of assessment services to our 756 client municipalities.  The Agency provides a financial foundation for municipalities and the education sector that they can use to establish and sustain local programs and services.

Lean is aimed at engaging the talents of the Agency’s people to eliminate waste, and create value for our customers.  With an ever-increasing workload and limited resources, Lean helps to ensure that SAMA’s clients’ and stakeholders’ needs are successfully met.

Thanks to the commitment of staff and Senior Management, SAMA is involving people throughout the Agency to tackle some of the challenges affecting the property assessment system in Saskatchewan.

“One of Lean’s strengths is its focus: the people most familiar with the actual work determine the necessary process improvements and plan the necessary changes,” said SAMA CEO Irwin Blank.  “The Agency has achieved significant progress to date, and Lean process improvement initiatives will continue to be a focus for SAMA in 2013 and beyond.”

Because the Agency looks for input from staff and management in all eight of our regional offices across the province, as well as our central office in Regina, the Agency has opted to train all staff and managers in Lean processes.  Staff all receive Introduction to Lean training, and many staff have received further training in Lean processes and change management.  The Agency currently has 14 certified Green Belts, and 5 certified Black Belts.  There are an additional four certified Green Belts who are currently Black Belt candidates, as well as another 14 Green Belt candidates.  Six of SAMA’s Executives have also completed Green Belt training.

To help guide and steer the Agency’s Lean journey, SAMA uses value stream mapping to improve the Lean process.  One of these improvements was to develop a Lean Manual.  The manual outlines details on creating and managing value streams, organizing and executing Rapid Improvement Events and the roles and responsibilities of staff, value stream leaders, facilitators and others.  All staff can access the manual on SAMA’s intranet system.

SAMA currently has several value stream maps in progress representing the different areas of focus within the Agency. For the operations area (Assessment Services) SAMA has value streams for Data Verification, Revaluation, Support of Value and Industrial Assessments.  For the Agency’s support divisions SAMA has value streams for Revaluation Governance, Finance, Quality Assurance, Human Resources and Agency Planning.

SAMA’s original Lean goals were:

• A 25% increase in efficiency and productivity between 2009 and 2013;

• Highly engaged staff, that take ownership of the business processes; and

• An Agency in a much better position to meet the increasing demands from clients.

Under the Lean initiative the Agency has:

• Advanced the Agency’s annual property maintenance program by 3-4 months and in 2012 completed the work for 62% of our client municipalities by December 31^st.  In comparison, only 14% of client municipalities received their annual property maintenance by December 31^st in 2009.  Property maintenance occurs when municipalities request SAMA to do on-site inspections of specific individual properties, usually where significant developments or changes have been made that have altered the physical data on  a property.

• Increased property reinspection productivity 57% over four years from 761 properties per appraiser Full Time Equivalent (FTE) in 2008 to 1,198 properties per appraiser FTE in 2012.  Periodically, municipalities must have all their properties reinspected on-site to verify that physical data and valuations are accurate.

• Made changes to sales verification, market analysis and support of value processes and reduced total appraiser time to complete the 2009-2012 revaluation cycle by 28.1 FTEs or 22% – an average of 7.0 FTEs for each year of the program.  Sales verification and market analysis are two key components of the Agency’s revaluation work that happens on a four year cycle. SAMA is also required to participate in property appeals and provide full disclosure of how property values are determined. This responsibility for openness and full disclosure is part of what SAMA calls “support of value.”

SAMA’s 2014 to 2017 Lean goals are:

• Increase the number of properties that an appraiser can review by 80% from 1,029 to 1,850 properties annually using Lean business process and technology improvements.
• Double the number of properties that an appraiser can reinspect from 1,050 to 2,100 properties annually using Lean business process and technology improvements.
• Utilize Lean value-stream mapping events and other tools to increase the efficiency and effectiveness of work processes.
• Improve the efficiency and productivity of annual maintenance processes resulting in the reallocation of 14 FTEs to the property reinspection program by 2018.
• Based on continued significant growth expected in Saskatchewan’s energy and minerals sectors, the agency will progressively double the capacity of our industrial program by 2017.  Lean process improvements, software upgrades, cost model simplification and remote data collection tablets will improve the efficiency of the industrial property assessment program by 25%.

• Efficiencies will be attained in delivery of the revaluation and annual maintenance programs that will allow the reassignment of critical appraiser resources to the reinspection program – increasing the agency’s average capacity for reinspections from 8 FTEs in 2013 to 27 FTEs annually by 2018.

The agency will continue to build on the Lean improvements attained over the past five years. The plan takes a long term and careful approach to innovative new business processes, and it invests in technology to ensure the sustainability of the property assessment base and municipal and education property tax revenues.

The focus for 2014-17 will be on sustaining current levels of service for our governance responsibilities, continuing to improve the delivery of assessment valuation services to our clients, and building the capacity to enable the Agency to reinspect all properties at least once every 12 years.

SAMA’s Lean journey has been one of trial and error and learning from our missteps.  The Agency’s Lean transformation has required this learning process, which will ultimately help us move towards becoming a truly Lean organization. With a strong commitment and growing knowledge of Lean, SAMA is constantly looking for ways that Lean can influence and improve our everyday business, and in turn, help us provide our customers with the best service possible.

A very commonly-implemented intervention when attempting to “mistake-proof” a process involving humans is the double-check.

Double-checks are, by their nature, waste.  Often, double-checks are put in place as temporary stop-gap measures while more effective, value-adding countermeasures are devised and implemented.  While a perfectly-implemented double-check does indeed improve error rate, it does not come close to serving as effectively as a prevention-based mistake proof device (poka yoke) and should therefore be considered a weak intervention.

The prevailing theory behind a double-check is that, while a person will occasionally err when undertaking a task, with probability A, the process will be made more robust by inserting a double-check of the work of the original person.  The presumption is that the person doing the double-check will also occasionally err, with probability B, but that the combined probability of error emanating from the double-checked task will be geometrically lower (improved).  For example if the error rates of the original person performing the task is 10% (A=0.10) and the error rate of the double-checker is 15% (B = 0.15), the combined error rate of the double-checked process is now (0.10)(0.15)=0.015, nearly an order of magnitude improvement.

Actual results of such interventions in practice rarely match the theoretical improvement.  By understanding the factors leading to gaps in performance of double-checks, we can set out to implement double-checks in such a manner that efficacy is enhanced.

Factors leading to sub-optimal performance of a double-check

Often, a double-check step is inserted into a process “on the fly” without thoughtful planning to eliminate possible failure modes of the check itself.  Following are some common situations to avoid when considering a double-check for your process.

• Lack of clear definition (standard work) of how the double-check is to be performed
• Ineffective training of staff who are to perform the double-check
• Failure to design an independent double-check; one that only involves the person originating the work has a high likelihood of error due to confirmation bias, which can blind the person performing a check on his/her own work .
• When a second person is assigned to perform the double-check, confirmation bias can blind this person.  This can be caused by specific information being passed from the first to the second person prior to validation, the second person subconsciously deferring to the authority of the first person, or simply trusting that the first person could not have erred.  Any of this leads to the second person missing errors.
• Creeping complacency, due to a person knowing that someone else is in place to catch any mistakes he or she will make
• Interruptions during the double-check
• Rushing the double-check

Related, and equally common, is the issue of nobody being tasked with examining errors caught during the double-check and using that insight to drive focused root cause analysis and interventions upstream to eliminate as many of these failure modes as possible.

What can you do?

1. Assess and analyze any double-checks you already have in place.  Look for evidence of any of the above issues.  Ask to see the data showing what errors are being found.  Investigate what actions have been initiated as a result.
2. Before assuming that a double-check is the strongest mistake-proof device (poka yoke) that can be designed and implemented for a particular task within a given value stream, challenge yourself and your team to seek out stronger interventions.  Estimate the relative strength between multiple intervention ideas.
3. Where a double-check is the only course of action, either for the short term or for a longer time period, infuse these design principles:

• independence of the check, separated by time and space if possible to mitigate risk of “contaminating” the checker with information about the person originating the work, inputs, outputs, calculations, and judgement applied
• to simplify and make visual the double-check, create a checklist showing the specific steps to be undertaken
• create a physical environment for the double-check that will be free from distraction and which will make the task simplest
• carefully document the standard work, train those involved, and assess skill/capability of those who will be performing the check
• avoid having the same two people serving as checkee-checker on a sustained basis
• periodically assess efficacy of the check, in a blinded fashion and provide feedback
• instrument your check and specify roles to include those who will prepare, analyze, and act upon the errors caught by the check

4.   Seek to continually improve, through successive cycles of mistake proofing, until you can evolve beyond the use of double-checking

In his first year as President of the UTPA, Dr. Robert Nelsen recognized this challenge right away. He had a transformative vision for his University which required improved responsiveness in administrative functions, without any increase in cost. The university had focused on improving the quality of its curriculum and educational resources without giving much thought to the transactional business functions. Until now, they simply had not been a priority. For him to accomplish his vision, Dr. Nelsen simply could not ask for more money from the UT program, he had to find a way to get more out of the resources he already had. Dr. Nelsen was familiar with the concept of LEAN at an enterprise level, and suspected he could achieve his goals through the identification and elimination of waste and improvement in the flow of tasks. He discussed this idea with an industry colleague, George Reynolds, a pioneer in developing lean transactional processes and formerly employed by Northrop Grumman Corporation as their Director of University Programs and Process Improvement. George agreed to provide some training and assistance to UTPA. After some discussion, both parties agreed to look at the procurement process at UTPA, and establish it as a test case to see if the lean methodology would “work” in an academic environment, and also to see whether it was possible to train UTPA staff to use lean methodology, so that they could continue to make improvements after the Northrop Grumman team left.

In October, 2010, George brought along a Master Black Belt to help observe the procurement process and facilitate a three day Value Stream Mapping event, focused primarily on the procurement process. A VSM, or “Value Stream Map” is a visual representation of a process that is intended to deliver value to a customer. It provides a structured approach for “seeing” the sequence of events required to deliver customer value and defines how each step in the process impacts what the customer values. The VSM shows how the processes link together in a ‘value chain’ and the map provides a way of “seeing” opportunities to minimize waste and improve process performance. The real strength of the VSM approach is in gathering people from different disciplines to see and talk about the flow of processes in a common language, and at a common contextual level. Once the problems are seen in the context of the overall process flow, their impact on performance can be measured, and countermeasures/improvements can be made. This effort using the VSM culminates in designing a detailed Future State Plan and vision to move forward.

The UTPA team went right to work, embracing the idea that they had control of their own destiny. The team quickly outlined the process they intended to improve (2), connecting each process step and output to a customer. This outline framed the starting and stopping points for a more detailed look at the procurement process, which the team mapped in great detail (3). With this detailed view of the process, the team was able to identify the “friction points” in the process – the things that got in the way and slowed things down.

The more detailed map also allowed the team to measure the individual process steps from a time standpoint. As part of the VSM process used by George’s team, the relative variation in time associated with the “friction” in the process was also measured. The facilitator used this specific measure of time and variation to create a Monte Carlo simulation of the time spent in the procurement process, and the relative impact of the variation in time as it impacts the overall process lead time. The marriage of visual representation of the process friction (pain points), and modeled impact on overall lead time helped the UTPA team focus on the “most important” things to work on. They spent almost a day of their time together coming up with, and prioritizing improvement ideas to make the procurement process “better”. While there were dozens of ideas for improvement, the team was able to resolve that all the ideas centered on five basic themes:

1. Lack of Visibility for information
2. Lack of Flow – process stops without warning and waits
3. Choosing the Wrong Path / Routing Errors
4. Training / Insufficient Knowledge – the people involved with the process just were not sure what to do.
5. Infrastructure – The tools (hardware and software) were not adequate to support the procurement needs.

The final day of the three- day VSM process was used to synthesize the process improvement ideas into specific actions (“WHO is going to do WHAT by WHEN”). This involved a lot of discussion, trade-offs, negotiation and estimation of costs and impacts, and is always much more intensive than it sounds. With each improvement idea, the team estimated the relative impact the “fix” would have on the overall procurement lead time, and a “future state” Monte Carlo simulation was used to model the overall expected impact on performance. The ability to visually model the impact allowed the team to focus on solutions that involved the most “bang for the buck”. At the end of the third day, the UTPA team was exhausted, but satisfied. They had addressed the specific changes they needed to make to the process, each dealing with manageable actions that are summarized below.

• Visibility – Understanding where the information is, who has it, and the status of the process
• Priority – Understanding which tasks are more important than others
• Trigger – How to signal that work needs to be done, or that additional emphasis/priority is needed to keep the procurement moving forward
• Handoffs – Minimize the “in box / out box” waits from handing tasks back and forth to different functional organizations. Maximize the amount of work that can be accomplished at one time by each group.
• Delegate – Trust others to accomplish their jobs, and hold them accountable for success
• Metrics – Measure the current process to establish how well it services the stakeholder’s needs
• Better Tools – Improve the ability to flow work, provide priority and visibility and extract information out of the Oracle Database
• Organizational Efficiency – Reorganize the group to be more efficient. House complementary functions under the same organization

The impact of improvement impact was re-modeled using the Monte Carlo approach, and the “Future State” process time was compared to the Current State. Improvements to specific process paths were modeled to be ~ 30% (5), except for the Sole Provider Procurement process, which involved improvements that were out of scope for this initial effort.

At each step of the process, the facilitator instructed the team about the theories of lean and continuous improvement that were used. He further taught the practitioners how to created and model their own maps, so they could continue to develop their improvement skills without the need to bring in expensive consultants each time. As highly engaged and intelligent groups often do, they embraced the concepts of the process improvement paradigm, and diligently went off and worked the action items. Within a few months, the team had met the expectations of the modeled performance, but saw the opportunity to do even more. They met with smaller teams, and continued the process of problem identification and problem resolution. Without increasing costs or headcount, they were able to bring the lead time for the procurement process down by almost 50%!

What happened next was even better – the UTPA staff became encouraged by the success they experienced in the procurement process, and started to map other elements of the administrative and transactional processes. While not every process was capable of a 50% reduction in lead time, each process was capable of being made better without adding more cost or resources. In fact, there was no magic to the improvement effort itself, it was the result of key stakeholders paying attention to what was happening, assessing the current state information, identifying the problems and simply deciding to do things a little better. We call this type of change “continuous improvement”, and it enables us to get control of the seemingly chaotic things that make it difficult for us to succeed at work.

Dr. Nelsen states: “It was the little things that made a big difference. Once we really started looking, we started seeing. Once we saw, we asked questions and then really listened to the people working in the process. They had the answers; we just needed a way to get to them – after that, knowing how to act was much easier. The Continuous Improvement folks helped us figure out what to measure, where to look, and how to listen, it was a great help.”

He goes on to note: “We have a long way to go to get where we want to be. But this is a great start, and now we know that we can ‘get there from here’.”

Yes, good things ARE happening at the University of Texas Pan American. Small improvements add together incrementally, and lead to big changes. According to George Reynolds, the former Director of University Relations and Process Improvement at Northrop Grumman : “All we need are good people, the desire to look, the patience to listen and the guts to act.”

First, let’s alleviate the misconception, apprehension or anxiety that Lean doesn’t work.  It does work!

The caveat is that you must discover the ‘right’ or proper adaptation of the thinking and concept to  your unique situation!

Next, there is no one cookie-cutter solution that can be used to solve every situation and needs of an organization.  It is obvious, that every organization and every division in every organization has their own culture, leadership, and human dynamics which are distinctive to them.

So, in order for Lean to be effective, these nuances must be dealt with by altering the approach that is used to effectively create sustainable ongoing positive impact for the business, their clients and their staff.

Thirdly, Lean is not a tool!

Most organizations go into Lean thinking that if they learn the theory and five phases, or tools like 5S, Mistake-Proofing, flow, Six sigma etc., they just have to get everyone doing that across all the departments.  We have seen places that pick one tool and focus on it for years on end and expect to reach their potential.  It won’t work!

Lean is a cultural change that requires those tools but more importantly, it requires the leadership and staff to change the way they analyze and question their business and how they perceive their client’s needs (value).

Fourth, change won’t happen overnight – this is not a magical potion that will automatically cure what the organization have currently created and evolved into over the past years or decades.  Lean is a long term continuous journey (most say this but most still expect overnight success and then move on to the next thing).

Fifth, reading the books and being knowledgeable about the theory, tools and basics is not going to prepare you for leading a Lean implementation.

There are many more but let’s start with those as it gives you an idea of the significant foundational concepts you need to be aware of.

Once you have acknowledged the above, you can then begin to search for the proper solution.  Chances are you will try to find the expert internally first and then if you feel you don’t have the internal expert you go outside to either hire someone or find a credible consultant.

In Part 3, we will begin to at least highlight some of the red flags to be aware of when hiring a person(s) to lead the change in your organization and that you are willing to put your reputation on the line for….

Challenge: Not all senior leaders have the vision, understanding and/or have “bought in” to making Lean a priority.

This is one of the critical steps and foundation blocks that must be in place to ensure the success of any Lean Transformation and Organizational Culture Change.

Root Cause: In our brainstorming sessions, the following were identified as some of the possible reasons this occurs.

• Lack of Knowledge/Education about what lean truly is and its benefits.
• Not aligned with Strategic Goals
• No clear metrics or goals associated
• Unclear about the Return on Investment
• Lack of ongoing communication
• Cultural issues internally
• Conflicting priorities
• Control
• Trust
• Resources to support and sustain lean
• Fear of this being just another “flavour of the month”

Each root cause listed above impacts leadership support and each one of those challenges requires an investigation to determine what would need to be in place to most effectively address them.

Possible Solutions:

Some of the possible solutions or ideas that could help to begin to address the challenge of achieving Senior Leadership buy in were as follows:

• Help Senior Leadership understand the value and overall system impact to create the vision
• Learn to speak the language of the Sr Leadership team and what is important to them
• Demonstrate the ROI of Lean through metrics meaningful to Leaders and its Strategic Alignment within the Organization
• Create capacity with staff and allocate resources to support the vision
• Create small wins which tie into the larger picture and work towards winning over naysayers
• Establish Goals and Focused Scope of Project
• Within you sphere of influence, create a pro-active and empowered culture

These are some of the potential solutions that were identified from our session and are worthy of investigation and strategy. Lean Advisors employs senior consultants who are veterans in the industries they serve. To learn more about how we can help you make your organization everything that it can be, contact us.

In 2008, the Montfort Hospital emergency room was one of the province’s worst. Its sickest patients waited up to 20 hours to be admitted. Patients complained and nurses quit. Morale was low and turnover was high. The nurses who remained were overworked and burnt out.

Occasionally, staff frustration boiled over; patients either left without being treated, or went public with stories about rude behaviour and substandard care. The hospital became a focus of negative headlines. “It was a crisis,” admits François Lemaire, Montfort’s clinical director of the ER.

These days, Montfort is no longer a laggard among Ontario’s busiest ERs. Its wait time for the sickest patients is 10 hours — half of what it was in 2008 — even though the volume of patients continues to rise. From 35,000 patients in 2008, the ER now treats 52,000 annually. Many of them are sicker and harder to treat than patients in the past. Yet despite these challenges, Montfort’s wait time continues to fall.

A recent survey of Ontario hospitals indicated that nine out of 10 patients would recommend Montfort’s emergency department to their family and friends. And the turnover in ER nurses is so low that there are currently no full-time openings — a dramatic change from 2008 when there were 15 vacant positions.

The turnaround, aided by $3.7 million in provincial funding since 2008, is one example of how Montfort says it has improved patient care by using practices made famous by Toyota. With the hospital-wide introduction of checklists, streamlining, standardization and non-stop brainstorming with front-line staff, Montfort has joined a growing number of acute-care centres in bringing the efficiency of a factory floor to health care.

The approach, known as lean, has long helped the auto and aerospace industries reduce waste and boost value for customers through continuous small improvements. With a cash-strapped government trying to rein in health spending, Ontario hospitals are catching up, spurred by provincial directives to do more with less.

Nowhere is the need for improved efficiency more critical than in emergency rooms, where speedy care is a key component of good care.

Montfort’s transformation began in January 2009, to teach its staff the lean principles. The hospital paid for the lean consultants with some of the $687,000 it received that year for ER improvement.

The money was part of a four-year, $400-million provincial program called Pay For Results. When it was launched in 2008, Montfort was among 23 of Ontario’s poorest-performing ERs to receive the funding, which gets clawed out of their annual budgets if they don’t show improvement.

Hospital staff deconstructed every aspect of how patients moved through the ER, from the time they arrived by ambulance or car until they were discharged. They examined the “flow” of patients — how they were assessed at triage, how they got their lab tests and diagnostic scans, how they were discharged or admitted and how information moved with them at each stage. They attacked the problem in the same way that factory managers studied the parts of an assembly line.

“We were a whole bunch of people with Post-it notes on the floor that showed all the different steps,” recalls Sophie Audet, an ER nurse. “After it was done, everybody looked at each other and started saying, ‘Oh my God. No wonder we’re so tired.’ There were so many steps. When you see it, you actually realize that.”

Audet and her colleagues worked to simplify the journey for patients and reduce unnecessary tasks for staff. To their surprise, the best ideas were not necessarily flashy, or expensive to implement.

Among other things, a daily activity report was introduced that gave every hospital worker — from the chief executive to department heads, physicians, nurses and housekeeping staff — a snapshot of the traffic in and out of Montfort. It listed the number of patients waiting to be admitted and discharged.

For the first time, staff got a bird’s-eye view of where the hospital’s bottlenecks were. They could also see which departments needed extra help to move patients along. “You see the big picture, not just your own little department,” says Audet.

In the ER, a low-tech whiteboard was introduced. It tracked the location and status of every patient and listed what services they were waiting for. For the first time, method and transparency were imposed, allowing the nursing team to manage patients more quickly and effectively. The approach also reduced the chances of patients being lost in the shuffle.

“Before, we used to write down everything by hand,” says Johanne Gougeon, the ER’s lead nurse. “Now, we write on magnets. If we have a patient go somewhere, we just move the magnet around. It’s on the board, it’s written out, it’s all standardized and everybody can see what’s happening.”

In addition, the triage process was simplified for patients with minor complaints. And the workflow of the diagnostic imaging department as well as the work schedules of housekeeping staff were adjusted to conform with the ER’s busiest times of the day.

Other changes related to inconveniences in the physical layout that added up to hours of lost productivity every day.

For example, the storage and labelling of medical supplies were standardized so that nurses did not waste precious time searching for surgical dressings or catheters. A method was introduced to manage wheelchairs, which were never available when staff needed them, leading to longer-than-necessary delays for patients waiting to be moved or discharged.

“We (drew) a line on the floor and we put up a sign: ‘Three wheelchairs here,’ ” says Lise Vaillancourt, director of clinical services. “All of a sudden, when somebody was done with a wheelchair, they knew what to do with it.”

Even a simple procedure like urine analysis often kept patients waiting because the fridge where the samples were stored was far from the nursing station. “We calculated that the nurse had to walk something like 150 steps and another 150 steps back an average of 75 times per day,” says Vaillancourt. “So we just took the fridge and put it under the counter. Now, it’s zero steps.”

Based on these seemingly minor improvements, ER wait times at Montfort fell by 10 per cent within three months.

Meanwhile, other changes happening hospital-wide also helped to ease some of the ER congestion. Physicians and nurses started to emphasize discharge planning almost as soon as patients were admitted. In the past, discharge planning only took place toward the end of a patient’s stay, which often led to extra days spent unnecessarily in the hospital. The resulting bed shortages triggered a backlog of patients waiting in the ER to be admitted.

Another change involved introducing a system of early-warning signs that flagged hospital staff about imminent overcrowding, giving them more lead time to plan for a higher number of patients.

By 2010, two years after Montfort introduced lean, its ER was among three that were recognized as the most improved in the province. That year, the department was awarded a $200,000 bonus under Pay for Results. By then, the ER had left its cramped and aging space for a brand new facility that was double its previous size, part of the hospital’s $300-million expansion of its premises on Montreal Road.

The new space allowed for even more ER efficiencies to be introduced.

These days, when patients walk into the Montfort’s ER, one of the first things they see are signs telling them what the estimated waiting time is. Based on how serious their illnesses or injuries are, they are directed to different waiting areas and treatment zones. They take a number to wait so they know how many patients are ahead of them.

Instead of having nurses or porters accompany the walking wounded to get their diagnostic scans, there are colour-coded lines on the floor that guide patients to where they need to go. In the past, patient care suffered in part because staff spent so much time shuttling patients back and forth.

Hospital officials say patients, especially those with minor complaints, are now so savvy that they’ll call ahead to check Montfort’s wait times against those of The Ottawa Hospital or Queensway Carleton. “Now, people are shopping around,” says Lemaire, the ER director. “This is our reality.”

Excerpt from the Ottawa Citizen
To Read more: http://www.ottawacitizen.com/health/Toyota+style+management+helps+Montfort+wait+times/7427615/story.html

The federal government’s overhaul of Canada’s refugee determination system is driving the Immigration and Refugee Board to embrace business efficiency practices pioneered six decades ago by Japanese automaker Toyota.

Ahead of the expected December implementation of the Protecting Canada’s Immigration System Act, the IRB is turning to “Lean” processes that it hopes will enable it to deal with refugee applications and appeals much more expeditiously.

The new law imposes tight statutory time frames for the board to hear and decide applications and appeals. Whereas it now takes an average of 19 months for the IRB’s refugee protection division to complete an initial hearing, the revised system requires that to be done within 30 to 60 days.

For those whose claims are denied, a new refugee appeal division must hear cases within 60 to 90 days, and reach decisions in as little as 30 days. Further complicating the IRB’s task is a backlog of more than 38,000 refugee claims it has yet to deal with.

“Compliance with these time frames requires the IRB to transform the way it operates so that it can hear and decide refugee claims and appeals much faster that is currently the case,” the board says in an email, adding that a Lean transformation is “particularly appropriate for an organization undergoing fundamental change.”

In a nutshell, Lean practices identify and eliminate all activities in a process that don’t add value for the intended customer. The result can be dramatic improvements in efficiency.

The IRB started down the Lean road in late 2010 following passage of an earlier government initiative, the Balance Refugee Reform Act. Earlier this month, spurred on by the latest reforms, it advertised for a consultant to “facilitate Lean business process improvements.”

The goal, the IRB said, is to “yield a sustainable refugee determination process that will meet the legislated timelines while ensuring that cases are dealt with efficiently, fairly and in accordance with the law.”

While Lean practices are still relatively rare in Canada’s public sector, they are becoming more common as government departments and agencies grapple with shrinking resources coupled with steady or growing demand for services.

Canada Post adopted Lean nearly two decades ago and the Royal Canadian Mint has been doing the same for nearly a decade. The Export Development Corporation and Passport Canada are also on a Lean diet.

But the Canadian leader in Lean is the government of Saskatchewan. After the Lean approach saved millions of dollars and cut wait times for treatment in the province’s health-care system, Premier Brad Wall expanded the initiative to all government ministries in 2010. Earlier this year, he even appointed a cabinet minister, Nancy Heppner, with specific responsibility for the Lean initiative.

Despite their roots in manufacturing, Lean ideas are readily transferable to any public sector process that involves multiple steps, says Mike Miles, director of the MBA program at the University of Ottawa’s Telfer School of Management.

“Any approach that forces people to sit down and ask themselves the question, ‘Where are we wasting time, money and energy,’ that’s a good process,” he says.

At the Mint, Lean practices cut the time to develop a new product in half, doubled the throughput of coins in some areas and simplified many steps and processes. Lean also helped the Mint transform a $3-million loss in 2003 into a record $68-million profit in 2009.

Steve Read, VP Corporate Services and CFO of Brockville General Hospital in Brockville, Ontario, draws on his background in the manufacturing sector as his organization adjusts to a tough fiscal environment.  “The economy influences how governments choose to fund healthcare,” says Read, “and right now the industry is going through a transformation where resources are tight and there’s pressure on all aspects of the healthcare system to rethink their processes and rethink the way they operate.”

In Read’s previous role, having to adapt was a given – manufacturing in particular has been transforming itself for decades, drawing on methodologies such as Lean, Six Sigma, Just in Time, and Total Quality Management.  Today, these approaches are commonplace in virtually every industry, including healthcare.

The fact that these methods, Lean in particular, help organizations do more with less makes them particularly applicable to today’s healthcare challenges. “In hospital administration specifically, the options to deal with financial constraints are fewer than they are in industry,” says Read.  “We cannot, for example, make a unilateral decision to not provide a particular service because it is not contributing to our financial plan.”

The need to provide the best possible care with limited resources prompted the CEO of St. Joseph’s Health System in Hamilton, Ontario, Dr. Kevin Smith, to engage the Lean consulting arm of Japanese automaker Toyota.  While there were initial questions as to why hospital administrators were visiting a car plant, Smith’s management team found that when they looked at Toyota from a process perspective, there was much to be learned.

“We saw that they had very good systems in place for creating flow, improving processes, and standardizing their work, all of which are very relevant to our work looking after patients,” says Smith.  “They also had very clear models for course correction when that may have been required, and rapid intervention in case of a problem.”

The processes were underlined by a continuous drive to do things “better, faster, cheaper”, and the empowerment of employees.  “Toyota really took people who do the work, gave them training and skills, allowed them to make changes in how they do their work as a team,” says Smith.  “The attitude was, ‘if it works, continue, if not, let’s figure out why, or move on to the next idea.’”

Seeing the Big Picture

The key to the common ground between hospital and industry is the customer, says former plant manager Larry Coté, whose firm, Ottawa-based Lean Advisors Inc., provides Lean consulting and training to healthcare providers across Canada.  “It’s not about cars and whether that’s similar to healthcare,” says Coté  “It’s that they both have processes that provide something of value to a client.  As far as the analysis, the thinking is very similar because you are looking at what is value from the perspective of the client, or the patient going through the medical system.”

The healthcare experience, of course, transcends many functional groups as the patient interacts with doctors, nurses, lab personnel, and administrators.  “Looking at all these interactions from the patient perspective forces decision-makers to consider the big picture that starts when a patient approaches the hospital or clinic seeking help, and concludes when the patient is dispatched after having received the required care,” says Coté.

Hospitals perform best when processes are in place that allow patients to flow through the system at a steady, manageable pace.  When patient flow is achieved, staff don’t get spikes of activity where they are overworked, patients don’t have to wait between processes, and the best quality is achieved at the lowest cost.  This kind of process environment can be implemented in a hospital, a factory, or virtually any other work scenario.

Two other components – information flow and communication flow – are also essential, as they make it possible for different functional groups to perform as a unified entity from the patient perspective.  These flows are also key to eliminating the waste that occurs throughout the system.

“By focusing on these things as a system, as a process that goes beyond functional centres and specific tasks, I think the healthcare sector is finding the same things that industrial sectors found,” says Read, “ – that there is waste to be found, and there are ways of eliminating it, and there are techniques that can be used to facilitate that.”

Managing Between the Processes

One of the most visible symptoms of waste in healthcare is patients sitting around in waiting rooms, taking up space in already-crowded facilities.  Smith recalls a simple question posed by a visiting advisor from Toyota who was viewing their ER – if waiting is not a good thing, why are there waiting rooms?  Smith says he was initially puzzled by the question, but then saw its implications.

“If you don’t have a waiting room, much like not having storage capacity in a car line, things are going to start backing up, and you’re going to have to start to figure out a different way of doing things,” says Smith.  By reducing the available space to conveniently “tuck patients away”, St. Joseph’s subsequently found ways to reduce ER wait times, save valuable space, and furthermore, to use the space to provide treatment on the spot for children’s ear infections and other routine, non-confidential situations.

One of the challenges of operating an electrical utility is that the grid has to be constantly updated to meet customer demand. This calls for a coordinated effort from many individuals; every time a new building is added, design documents have to be created and approved, parts have to be ordered, and crews have to be allocated.

In late 2010, Hydro Ottawa enlisted Lean Advisors to help reduce project lead times and improve efficiency. After a series of training seminars, multi-functional teams used the Lean Value Stream Mapping (VSM) tool to analyze the entire project delivery process, from request of a new service to final hookup.  By mapping out the current and desired future states for the entire value stream, participants were able to create a roadmap for improvement across the three functional areas involved – design, installation, and material management.

“We are definitely trying to address this value stream, because it crosses so many different departments,” says Brent Fletcher, Hydro Ottawa’s Manager of  Business Performance. “Instead of pointing fingers we think that we can deliver a process that is better for everybody. It will keep our inventory down, our carrying costs down, reduce the number of parts being returned, and ensure the parts are where they need to be when they need to be so that execution doesn’t slow down.”

One of the breakthroughs was to align teams by region. “Instead of 22 designers working in all parts of the city,” says Fletcher, “we’ve aligned our designers geographically to help build relationships with the local construction forces, develop a stronger knowledge of their area, and improve communications.”

The biggest impact of Lean, however, has been a marked improvement in the working relationship between the groups, who have improved communications, reduced lead times on designs getting out, and improved the accuracy of the designs.

Scheduling is now done through bi-weekly meetings where upcoming projects can be reviewed from end to end. “We are giving more clarity and visibility to the schedule, and where our resources are being used,” says Fletcher, “and also more advanced notice of jobs that are coming up.”

The groups are currently looking at ways to deliver materials more efficiently to jobsites. “We are looking to reduce inventory, and are finding ways to ensure that when a crew shows up in the morning they have everything they need in order to execute on the job,” says Tony Mittiga, senior advisor with Lean Advisors, who is consulting on the project.  The key will be a Just-In-Time approach where crews are supplied with smaller batches of materials on an as-needed basis, as opposed to larger shipments that tend to clog up jobsites.

Feedback from the field has been decisively positive.  “We are definitely, anecdotally and qualitatively, getting very good feedback from the workers and from the designers,” says Fletcher.

“They are making quite a bit of progress,” says Mittiga. “I think the interesting thing is the enthusiasm from the team members. They really, really want to see things happen.”