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visit MIT OpenCourseWare at ocw.mit.edu. SUSAN SHEEHY: So I just want to
do an overview of healthcare, lean for healthcare,
because you've learned a lot in the last couple of days. And how do you apply
this at the front line-- at the front lines of
hospital or healthcare? So just to give you a little bit
of an overview of our company, our company's stationed-- or
the headquarters is in Montana. We've worked with about 115
healthcare organizations, mostly hospitals. We've had some other
kinds of organizations like Johnson Johnson,
Blue Cross, Penn State, some universities as
well as medical centers, from 50 bed centers
to 1,200 bed centers. So Lean works across the
board in every department in every organization in
the healthcare system, lean for healthcare. Matthew May wrote a
really nice little book. And I was telling Earl
about it at the break. It's a little paperback book. You can get it on Amazon for $2. It's called The Elegant
Solution by Matthew May, and it's about Lean,
not only about lean for healthcare but it's
an awesome little book. It takes about an hour
and a half to read. And what Matthew May
says is Lean doesn't light a fire under people. It lights a fire within
people, because it's really an exciting thing to bring
to a healthcare organization. Why Lean? Because it's a great fit for
healthcare organizations. It produces meaningful, useful,
important results right away. And it provides
a power to change an entire culture
of an organization, if you do it right. One of the things we have to
ask ourselves in healthcare is, is there a better way
to do what we're doing? So I put this. This is my administration slide. And this is how
we do what we do. And the answer we
always get in healthcare is because that's the
way we've always done it. So lean is the systematic
pursuit of perfection, and it's a discipline
of incremental changes, one little step at a time. You're not going to come in and
change the world in six months. Taiichi Ono, who was
the president of Toyota, said it's better to make a
2% improvement every month than a 24% improvement one month
and none the rest of the year, because what happens
is it doesn't embed the philosophy of
continuous improvement and continuous change. So you have to intermingle
your rapid improvement events with lean sustainability
across the board as well, really important. And in our experience,
a lean transformation in healthcare organization takes
four, five, six years at least, depending on the commitment
of the administration and the ability to actually
educate and train the staff. There's no quick easy way. People think of
lean as a quick fix. It's not. It's a good fix, but
it's not a quick fix. It's learned through
experiences, clinical and operational experiences. It takes practice,
practice, and more practice. One of the questions that
came up is it's too risky. If you take a risk,
you might fail. Well, yeah. But if you don't take a
risk, you are going to fail. So it's important
to take some risks and give some new things a try. In order for lean to succeed-- and I'll intersperse
it through my talk-- the entire healthcare
team has to own it. It's really bad for a
CEO to hire a consultant to come in and fix things
for you, and then they leave. Everybody has to own it--
the senior administrators, middle managers, and
the front line staff. It has to be evident
in everyday work. Somebody sees a problem. Let's do an A3 on that
and fix it right now. It has to be embedded
and practiced by everyone in the organization. And it has to be expected of
everyone in the organization, not just one or two activities,
but across the board. I used to be a director years
ago before I knew about lean. And someone would come
to me with a problem. And I'd say, don't come
to me with a problem. Come to me with a solution. And that is the absolute
wrong thing to say. Come to me with what the
issue is and background, and we together will
work on the solution. That's how lean is. So managers are no
longer dictators. Managers become coaches
and barrier removers. That's how lean succeeds. This is what we hear in
healthcare, because that's the way we've always done it. And Mr. Einstein said the
significant problems we face cannot be solved at the same
level of thinking we were at when we created them. Why Toyota production system? Why lean for healthcare? They make cars. We take care of people. Well, first of all, they're the
most successful manufacturer in the world, most people think. Can it work for healthcare? Let's see. They have the best record of
introducing new technology. Well, guess what? We have a technological
imperative in healthcare. We have to do that. Best record of
employee satisfaction. We have to keep our
employees with us. Retention, happy-- employees
who stay are important. Relentless commitment
to eliminating waste. And heaven knows we have a
ton of waste in healthcare. One million suggestions
a year Toyota expects from their employees,
and they implement over 90% of their suggestions. And those employees
feel very valued. And who better to tell
us how to fix our system than the front line workers? Who better to tell us how to
clean a bed than the cleaning lady? Who better to tell us how to
prepare a tray than somebody from the cafeteria? Not somebody from
here who says, I want you to deliver those
trays better with hotter food. We need to go ask them,
why is the food not hot? Features of Toyota
production system, a.k.a. lean-- management
is not top-down. Healthcare has a traditional
model of command and control. Can't do that anymore. Toyota also has a
model of employees being on the value
side of the ledger, and not on the
expense side, even though they are an expense. Healthcare, we have
just the opposite. We put employees on
the expense side. We need to cut budget. We cut physicians. We need to think differently. We need to take the people
who are doing the work and recognize them
as the experts. This is work we did at
Mount Sinai in New York when they were implementing
Epic, a big massive software, medical software program. They wanted to fix
their processes first, their clinical
processes, and then do the Epic builds based
on their newly renovated clinical processes, rather
than building Epic and then trying to fit the
processes into those. So we asked the people
who are doing the work to do the mapping of their
processes, and we coached. We had 56 nursing units to
work with, daunting task. Imagine what would
happen in a hospital if every employee
in that hospital was empowered to do lean,
to identify problems and issues every day,
to identify barriers to them getting their work done,
to allow them to make needed changes on a daily basis. It's the power of 1,000,
or 2,000, or however many employees you have. Bill Bradel who's the CEO at
Northern Arizona Healthcare calls lean the best
thing since penicillin. He says it's the best thing that
ever happened to him as a CEO. Why Lean? Lean gives employees a
purpose, a direction, a sense of belonging, a
sense of contributing, a different way
to think and work, and an opportunity to build
a better work environment. I finished a project
recently where a cleaning lady discovered
$750,000 of waste, getting rid of hazardous waste
material that really wasn't hazardous waste, a cleaning lady
who came to my class and said, I don't think I have
anything to offer. Hello. It was amazing. Why lean for healthcare? We talked about this earlier. It's the largest
industry in America. And the cost is going
up, and up, and up. And by 2019, it's
going to be almost 20% of our gross domestic product. We can't do that. It's not sustainable. What's happening is the reason
this is going up so fast is we have job
losses, and people who were originally
insured are now gone, going out to Medicaid. And we baby boomers, some of
us, are starting to retire and moving from Blue
Cross to Medicare. It costs money to do that. And it's going to
increase 7.4% annually, Medicare spending,
between 2011 and 2017, the big baby boomer surge. We also have to
figure out how we're going to take care of these
different populations. We've got baby boomers
who pretty much believe anything the doctor tells them. And we take advice. Gen Xers are a little
bit more skeptical. They're going to go on
Google and look something up. Millennials-- I have
a 26-year-old son who's going to come
with information, and he's going to tell
you what he needs done. The digital natives who are
the newest being born children want everything now
at home, online. So we have to
figure out how we're going to deliver healthcare. Why do I have to come into the
hospital for my blood test? Can't I just stick my
finger into my computer, and can't it just draw my
blood and give me a read out? Think about these things. Why not? Why not? Why does this work
for healthcare, again, massive waste in healthcare? It's estimated
that everything we do in healthcare between
50% to 60% of everything we do every day is
waste, 50% to 60%. Excuse me. Lean is rock solid common sense. It's very easy to learn and
teach at the front line. It's easy to apply at the front
line where work is happening, and improvement occurs
with the first application. Quick example. I had a security guard
in one of my classes. And I always say to
them, pick something that drives you crazy every
day when you come to work. That's going to be your project,
not a person but a process. And this security guard
says, OK, taking-- investigating lost false teeth. Sounds funny. Hospital's spending
$3,000 a week replacing lost false teeth. And this guy was writing
reports that went nowhere. So the first thing we have them
do is an observation exercise. He went to gemba, looked
around, came back, and said, I think I figured it out. Every room is designed
for a right handed person. So I'm in the bed. I'm the patient. I've got my bedside
table, my over bed table, and the trashcan. So I'm grandma, and I'm
not really good at night when I take off my
glasses, take off my teeth, go to put them on the table. They fall in the trashcan. Housekeeping comes in really
quietly, takes the bag, throws it away, gone,
never to be seen again. So he said, I
moved the trashcans on the left side of the bed
this week, and I watched. We found teeth on the floor,
but we didn't lose any. Security guard. Wasted time-- this is a study
done by John Kenagy, who's Boston based. He actually lives in Belmont. Dr. Kanegy and his group looked
at 1,000 hours of nursing work across a number
of organizations. And what they found is only
a third of nurses' time is spent at the
bedside, one third. Another 24% or 25% is spent
with administrative things, paperwork, medication
reconciliation. And 43% was pure waste,
clarifying, hunting, reworking, redundancy, checking, waiting. Think what we could
do with this time, if we could capture it back,
if we can put it in here, and get our patients out of
bed, and get them walking and do DVT prevention
and pressure sort prevention, shorter lengths
of stay, better outcomes. Everything we do in
lean and our mantra, and it should be
everything we do in lean must be patient focused. It's not about the physician. It's not about the nurse. It's not about the housekeeper. It's about that patient,
because that's why we're there. And the old mentality
in healthcare is we worked in siloes. I worked in the
ED for many years, and it's like, oh, my god,
this patient is going to die. I just don't want him
to die in my department. Let's get him to the OR. That was the old thinking. Now, we have to think
this is our patient, all of our patient. So I have a little
thing that I like. It's a piece of
artwork called mandala, where every point in a circle is
connected to every other point. And this is why I
like to think of how we need to think about
healthcare, with the patient in the middle supported by
every single department that's connected to every
single department. So it's no more
their fault. The ICU won't take my patient,
because the nurse is on break. And we never get a break. And we haven't had
lunch for three months, and they go to lunch every day. That's the kind of thing
that's got to stop. Another Einstein--
I love this saying. Everything must
be made as simple as possible but not
one bit simpler. So it needs to be a continuous
flow without the workarounds. The nurse goes into the
room to do something. The equipment isn't there. She has to go to
the supply room. She goes to the supply room. It isn't there. She has to go call
storeroom to get it. She comes back. She needs a medication. She goes to the Pyxis. It's not there. These are all called
workarounds, which prevent us from that continuous flow. And that's what we're looking
for in lean, continuous flow. Paul Batalden was a professor at
Dartmouth who recently retired. And he said that--
and this is absolutely true-- everyone in healthcare
must recognize that they have two jobs when they come to
work every day, doing the work and improving the work. So we all have to be
looking for waste. What can we do with
lean healthcare? Produce more defect
free health care, eliminate waste, improve
workplace appreciation for the people who do the work. And it also
strengthens leadership, because you have
a common dialogue. I'm going fast because I want to
show you some examples as well. So we need to ask ourselves
everyday in healthcare, are there things happening
to our patients that shouldn't be happening? We also need to ask
ourselves, are there things not happening
to our patients that should be happening? Every day, ask
yourself this question. Now, what does defect free mean? Defect free means exactly
what the patient needs when they need
it, without errors and that it's safe for the
patients and the staff. The mudas are pretty similar. We've tweaked them a
little bit for healthcare. And every organization
that deals with healthcare has them a little
bit differently, but these are ours. In my particular
company, they're pretty close to manufacturing--
most manufacturing. And we've added the
eighth one for us is matching people
skills with the task, because a study done by the
Wisconsin Nursing Intervention Outcomes Project
over 20 years showed that 16% of everything
nurses do clinically can be done by somebody else. So can we do that? Can we reassign some work
to make the right people be doing the right things? Confusion is a muda. In healthcare-- and these
are just some examples-- clarifying physician's orders,
medication reconciliation, which is such a headache. Patients come in, and
we have to find out what medications they're on. This is grandma. She comes in with a shopping
bag and pours her meds. Some are old. Some are new, from three
different pharmacies, five different doctors. Who knows? So you're spending hours. And the average med-surge
nurse spends about two hours doing a med reconciliation
on one patient, making phone calls. It's crazy. We have to figure out
how to embed computer chips in people's ear, so
that any time a medication changes it gets recorded
on the chip or something. Motion-- this is
waste in healthcare-- looking for supplies,
trying to find a chart, multiple diagnostic tests
in various locations. So you come to get the patient. Transportation comes. Oh, they're in X-ray. Housekeeping-- or dietary
comes to deliver their tray. Oh, they're in CT. Patients all over the place
with no central scheduling way to see where they are. Nonsensical staff assignments. I've worked in the
ER for 34 years. There was never a match
between the physician schedule and the nurse schedule. They were all different. And so trying to work as a
team, it took so much time to get everybody caught up
at all the different changes of schedule. And I have this
really strong feeling about nurses working
12 hour shifts, but that's another
band soapbox for me. It's horrible. And not having the
equipment you need. These are all
involved with motion. Waiting-- healthcare waiting,
waiting for appointments, waiting for transport to
arrive, waiting for the surgeon to come, so that the OR case
can start, waiting in an ED. What's wrong with this? Oxymoron-- emergency
room, waiting room. It doesn't make sense. Does it? Waiting for discharge orders,
waiting for meds to arrive. We wait non-stop. Processing-- not
having the things you need in the med container
Pyxis, complex and redundant paperwork. Have you ever gone to
a doctor's appointment to the hospital,
and three people ask you the same question? Processing that
incorporates workarounds. They're part of the plan. We don't even realize it. Insurance nuances, the worst. Inventory-- big problem, too
much of one thing, too little of another, expired items,
not the right things or not in the right place. My ER had nine different
kinds of arterial line trays. Every one had to be
calibrated differently. I had 97 nurses on my staff. What do you think
the expertise was in any nurse on any
one of those trays? And the physician's complained. I said, OK, let's get together. You're going to pick one. Sometimes, you have
to be a hard nose. Defects or errors--
in the IHR report, over 100,000 hospital deaths
each year due to errors that we make-- medication errors,
failure to rescue error. My father went in for
an outpatient procedure and died because
something happened, and they ignored it and did
something else, something that could have been rectified. Incorrect identifications-- two
people with the same last name. Wrong site surgeries,
and it happens. Wrong leg amputated, wrong
arm, wrong side, falls. Falls happen all the time. These are major errors. Healthcare is the largest
industry in the world. It's also the least reliable. We have an extremely
high defect rate. Hospitals may be hazardous
to your health, seriously. You come in, and the chances
of you getting an infection are not slim. Medicare has developed what
they call never events. If something happens
during your hospital stay-- and there's a big
list; these are examples-- they will not
pay for that treatment of that particular thing. Urinary tract infection,
pressure sores, hospital acquired pneumonias,
different kinds of infections-- if this happens during
the hospital stay, Medicare will not pay
for that treatment. The hospital has to suck it up. And it's a good thing, because
they should never happen. But why do they happen? Because people don't have time
to attend to these things. Or we don't have standard
ways we do our work. There's another thing that's
coming up that you may or may not have heard of. It's called value
based purchasing. This is another new
Medicare/Medicaid idea. It's scary, because
what they're going to do starting next
year is a portion-- every patient is assigned
a diagnostic revenue group, or DRG, and
you get paid a set amount for that diagnosis. They are going to withhold 1%
of the DRG payment from all hospitals, and then
it's going to be-- there's-- and this was
authorized by an act-- it allows a portion of that
Medicare and Medicaid payment to be withheld. And then, it will be reimbursed
to the hospital later based on performance. They'll get a score, a
value based revenue score. And then, they'll get incentives
to get that money back. So it's performance based. It'll include clinical measures. 70% are clinical. 30% are age gaps. If you don't know
what age gaps are, that's the patient's assessment
of how their care went. So if the patient doesn't say
you did a good job, guess what? You're not going
to get your money. These are the big four that
they're starting with in 2013-- heart failure, myocardial
infarction, pneumonia, and surgical care. And the list is going
to keep getting bigger. These are the proposed
things for 2014. They're going to look
at clinical outcomes, patient safety issues,
operational throughput, and mortality rates. Hospitals need to start
to get better or continue to get better. It's the lean imperative. I have CEOs who
say, we really can't afford to do lean
throughout the hospital. And our response
is, you can't afford to not do lean, because
as the number of metrics and complexity of
measures increases, it'll be vital to learn to
effectively design and manage overall delivery systems,
rather than targeting just select things like
door to needle time. That's great. Everybody does that,
or door to cath lab. It's going to be the
whole organization that's getting measured. So the whole organization has to
figure out how to address this. There's another, getting
back to the mudas-- overproduction--
different people asking the same
questions, multiple forms requesting the same
information, unnecessary lab or diagnostic tests. We have this a lot in academics,
and we reword everything, covering all bases. And overproduction,
again, different-- oh, didn't I just do that? Sorry. Excuse me. Ideal healthcare is exactly what
the patient needs, no more, no less, on demand, exactly
as requested with no waste. It's an immediate response
to a problem or a change, if that happens. And it's physically,
professionally, emotionally safe for patients and staff. Those are the ground rules. Now, in the-- a lot of
the lean sensible papers that have come out, there are
some really good information. And Bowen and Spear,
who are from this area, in their MBA work, looked at
the lean-- the Toyota production system. They said, basically,
there are four rules. Toyota has never stated them. But Bowen and Spear
identified them. So here are the four
rules about lean. All activities of work must
be specified, standard work. Content, timing,
sequencing, outcome would standardize how you
do an arterial line, how you admit a patient,
how you discharge a patient, how you order meds. The second rule-- and we
looked at this and said, how does this fit in-- every process in healthcare
has a map, a value stream map. Across the top is the
request for that process. And then across the middle is
the delivery of that process. So we interpreted this
as rule number two has to do with the
request for the process. So in the request,
all connections in the request or service
are simple and direct. Here's an example. Old way-- patient comes in. They want care in
the emergency room. They come in to the ER. They wait. They sign in. They wait. They go to the waiting room. They wait. They go to registration. They wait. They see the triage nurse. Maybe they go to an exam room. Maybe they wait. That's the request before
that patient even gets care. What we need to do is look
at that request and say, how can we get that
patient, comes into the ER, immediately through
triage or back into a bed? So how can we eliminate
a lot of these steps and make it less complex? Can we do that? Rule number three has to
do with the actual steps in the process itself. So rule number three is that
all pathways in the process to deliver the
request are simple and involve as few
steps as necessary. Do we need all of these steps? Can one person be doing
two tests instead of one? Can we consolidate some? Can we change the order? So again, this is the example
I gave you of the nurse. If we map this
nurse and how she's doing this procedure
for the patient, look at all the workarounds. And how can we get rid
of those workarounds and make it simple and direct? And rule number four is that
everything we do in lean needs to lead towards improvement. You don't change just
for the sake of change. And we've all been
through healthcares where we've done some
changes, and nobody knows why we made that change. So direct response to a
problem, as close to the problem as possible. Any change we make is first
tested in a smaller area or for a smaller period of
time to see if it works. And then, all the redesign
is done by the people who actually do the work. And supported by a coach. This is huge in
lean, need a coach who's not directly involved
in that project to help coach the people along. Now, you've learned about
value stream mapping. And I'll go through
it a little bit. We're also going to talk later
today about A3 problem solving. And people get a
little bit confused. So I say, OK, the forest
is the value stream map. And the value stream map
is when you analyze it, it is going to point to
where there are problems. It's not going to tell
you how to fix them. It just points to the problems. A3 problem solving is picking
those trees or those problems and pulling them out
and addressing each one. So you're dissecting
your map and figuring out how you're going to
address the problems. We always use the
scientific method in lean, where you always have
to do an observation. You can't make it
up in your head. And I always know when
my students have made up their value stream map in their
head, because all of their data is divisible by 5-- 0, 5, 10 seconds,
not odd numbers. And change is always done first
as an experiment or a test. We also use the
Socratic method-- which healthcare people,
I'm sure you are used to as well-- when we ask why. And we ask, how do you
know how to do your work? What's the next thing
that prompts you to do it? Why do you do it that way? Are there clear signals that
cue you to the next thing? Do all workers do the
task the same way? So we are going to
constantly be asking why, not only to get to root cause,
but to help the people we're coaching learn critical
thinking skills as well, so that they also
start to ask why. And the basic tenant of Toyota
production system, or lean, is to deeply understand how
the work currently happens before you try to fix it. This is really important. PDCA is the fix it part. We need a little
preliminary discussion about how it is now before we
go to what it's going to be. And I'll explain that a
little bit better in a minute. You have to go and
observe, bottom line. I love Yogi Bear. He has some of the
most awesome sayings. You can observe a
lot just by watching. Taiichi Ono said he challenges--
he challenged people to go stand in one
spot for 30 minutes and write down 30
things you would change that you're looking at. It's a challenge,
but it's interesting. I did it in my
kitchen, and I was so surprised at how many
things I needed to change. We talked about gemba,
going to look and see at the site with your eyes,
not only collecting data but using your qualitative
sense of what's going on. Experience the environment. Immerse yourself in it. Ask questions of the
people you're observing. Use an observation sheet. Use spaghetti diagrams,
whatever works for you. And I'm going to show you a
couple of different methods that we used. We had a client hospital where
they had seven phlebotomists and four floors. And they always
had trouble getting their morning blood draws done. And a lot of
decisions for the day had to do with the
morning blood results. So we took a look at it. And what happened was the
phlebotomists would come to the lab, pick
up some pink slips, which were the orders
for labs go to the floor. So here's the--
lists phlebotomists who went to the second
floor, drew three bloods, went back to the lab,
picked up more slips, went to the third floor. Drew some bloods,
went back to the lab. So you can see that
these seven phlebotomists were all over the place. And until we actually
drew this, they went, oh, no wonder
it takes us so long. We need to figure out how to
get all those slips together and one phlebotomist go to
each floor, or maybe two if it's a busy floor. But it was just like
a lot of these things are you don't even realize
it until you look at it. Here's another one. This is my very first
on my own trauma-- lean project. And I was at a
hospital where they wanted to look at trauma
patient throughput. It was taking
three to four hours to get a major trauma
patient through the emergency department. So we did a number of things. But one of the things
I wanted to look at is once we got the number
of people in the room down to a reasonable number,
what were they doing? So in order for me
to do this, so I had to look at six
different trauma cases, and spaghetti map one
individual at a time, and then overlay them. Spaghetti mapping
can teach you a lot. What we learned-- what
I learned from this is this a nurse in red. You can't see the
colors to well. This nurse was all over
the room and four times had to leave the room. So every time she left the room,
I said, why are you leaving? To get meds from the
refrigerator, to go get a warm blanket, to
get warm IV [INAUDIBLE],, to use the phone because
the phone's busy here. Looking at the motion,
why did this nurse have to go over here? Because the supplies he or
she needed was-- weren't here. Why was there congestion
coming down here? Never noticed this before. We had one trash can,
one phone, and one sink. Everybody was congregating
to that corner. So spaghetti mapping
can show you a lot. And then, this was when
we did a little bit different observation. A hospital in rural Maine
was having difficulty getting patients through
the nuclear treadmill test. It took too long. And these were the
mandatory steps. And then the red is wait times. So the person who came in--
this is before and after. The person who came in first
had the longest wait times from anybody. Now, why was that? They couldn't figure it out. And they had one
nuclear medicine tech who was getting
blamed for everything. So they came to me. They weren't in the
class I was teaching. But they said, can you help us? And they said, we did
a value stream map. And they brought out
this butcher paper that went around
three walls of a room for their value stream map. I said, whoa, this is
like input overload. What we needed to do was
take one patient, and what happens to that
one patient, what has to happen to
that one patient, because everything is timed
in nuclear medicine treadmill. They come in. They get an IV. They get some dye. They get a picture taken
at so many minutes. Then they have to wait. Then they go to the treadmill. They have so many
minutes on the treadmill. Then they have to wait. So we met one patient. And what would happen
with one patient? When we put that second patient
with the same steps next to it, we realized we-- you can't
schedule them at 30 minute increments, because that's not
the way it works, for that one tech to be able to handle these. So we started moving these
things to stagger them. And what we found out is you
do a little bit of a staggered admission, it works better
and that some of the tasks, like up here--
where's-- on here, [INAUDIBLE] med tech right here
had to be in four different places. No wonder he wasn't
getting his job done. So what we did was we
looked at what job the med tech had that we could
assign to someone else. So basically, it came
down to three times during the schedule a nurse had
to come down and start the IV. Everything else, he could do. What happened, if you look
at-- and the interesting thing was this schedule was set up at
the convenience of the doctor, because they wanted to read
all the results sequentially, without thinking about the
patients waiting around forever. So we met with the
doctors as well and said, OK, if we spread
these out a little bit, so you have a few minutes
between, is that OK? And they want to try it. Look what happened
when we did this. It opened up all of this time. They were able to schedule five
additional nuclear medicine tests a day, by just tweaking
that schedule a little bit. It's an observation. We didn't have to change
how they did their work. We just had to change how
they scheduled their work and some help for the people-- the one person who was
trying to do it all. So they thought I
walked on water. And it wasn't rocket science. It was just sitting
down and saying, OK, what did it take to get
one patient through, and then how do we move
the other patients through? Then, of course, in
the middle of all this with all the excitement of
opening up scheduling spaces, because they had lots
of patients in a queue, there was a worldwide
shortage of isotope. So they couldn't put that
many patients through. They couldn't get them--
the dye that they needed. Anyhow, value stream
mapping, we talked about. It's the view from 10,000
feet, the big picture, view. All activities in the value
stream map, once you get it, are recognized as value
or non-value added. And as I said, a
value stream map doesn't tell you what to do. It tells you where
to look for issues. And it's a springboard
to a future state map. So a value stream map-- as I said, what we do is we
do-- we divide the value stream map into three. Across the top from right
to left is the request. All the raise or
request can be made for whatever the process is. Whether it's a phone call,
an email, somebody coming and grabbing you in
the hall, all the ways, a request can be made. The middle section is the actual
steps to deliver the request. And then the bottom
was-- is where you add your data on how long
each of those process boxes takes. So here's one that just
shows you-- this is-- I didn't add data to
this yet, but this was a patient going from
the emergency department to a floor, once the decision
was made for that patient to be admitted. So we mapped out the process
of what has to happen or what is happening currently. And then, we went
back, and looked at, and said, where are
all the problem areas? We call these storm clouds. So we identified problem areas-- delayed information to the
nurse, delayed response, nurse not available
on the floor. And each one of
these storm clouds now becomes a topic
for A3 problem solving. So we're going to look at why
is there a delayed response? We're going to do,
why is the nurse not available on the floor? So you can chip away
with six or seven A3's to come up with a
really nice new value stream map that works better. Value stream map is going
to identify every way a request can be made. So this is one that we
did in a trauma system. This is how the patient
comes to the hospital. There's a trauma
patient needing care. So how do they get there? They come by helicopter. They come by ambulance. Helicopter radios into
a medical control. Ambulance calls in or radios
in to medical control. Medical control then calls
the appropriate hospital, either by radio or by telephone. So the jagged line is an
electronic communication. That's the request. What we forgot to
add in on this one was the drive by, where the
patient just came in a car and they dropped off. And then, what you need to
do is look at the request. Are there any problems
with the request? Because a lot of times,
your process is good, but the request
is all messed up. And that's where
the problem starts. So remember that you have
to go look at the process and capture it. I just take notes the
first time I'm observing. I don't try to draw the map. I take notes. Then I go back to my
office, draw the map, and then bring it back
to the people and say, did I get this right? Did I miss anything? Validate your map with
the people doing the work. That's really an important step. So in this particular
hospital, these were the steps that they identified. Here comes the trauma patient. Now, we're ready
to do the process. So the patients go
to the trauma room in the emergency department. They have assessments done. They have procedures done. They have blood work that's--
or blood that's coming. They go to imaging for
a CT scan or X-ray. And then decisions are
made about where they go. That's how they mapped
out their process. Value stream maps
are very useful, because it helps you understand
every step of the process, identify where
there are problems. It helps you launch
specific problem solving. If you have a current
state map, you can use that to
orient new staff. This is the way we do it. And it clearly describes the
process to other departments, if you're going and
saying, we have a problem with the OR and the ED. So let's bring the map
together and take a look at it. And it also shows
regulatory authorities, like Joint Commission
loves these. If you show them your work in
progress, they're so impressed. So here's this map. Once we got it mapped, we
looked at 10 trauma cases. And we like to do
30 sets of data. But to collect data on
30 major trauma patients would have taken way too long. So we thought 10 would
give us what we needed. We looked at each
process box, 10 patients. The highest in the trauma
room was 235 minutes, almost four hours. The lowest patient was--
we could get through in 36 minutes. And the average of all
10 was 187 minutes. So we didn't make
any judgments yet. We just went through and
mapped how much time. This time, we used
upside down deltas. That's our own little quirky
thing in Healthcare West. Delta means change. So we decided upside down
delta means no change, when nothing's happening. So these are delays. We did the map, and
then we put in the data. And then as a team,
we looked at this map and said, OK where
do we need to work? So I said, there's too
much variability here. We don't know what
we have to do yet, but we know we
have to look here. It takes too long. Too much variability in
how the procedures are done or how long it takes that may
be a factor of what procedures the patients need or not. We don't know that yet. Once the decision was made,
it was taking too long to get the patients to a
bed, more than an hour. When they said, this
patient needs to go, it took more than an hour. So this gave us the basis
for where we were going to do our problem solving. Once you do your
current state, you want to draw a future state map. What do you want
it to look like? And this is where
you really need to push people, to really push
with, what do you really want? Don't just put a Band-Aid
on a leaky trash bag and move that trash bag to
somebody else's department. What do you want? And I would say, if
you were the emperor or the empress for the day, how
would you want this to look? They're like, oh,
we can't do it. I said just put it down. How would you want it to look? And then, let's compare your
current state and future state and figure out what
problems we have to solve to get you
to your future state. Really important to have
that vision and future state and to push, push for just
not mediocre but really push. So this is what happens. You draw a current state
map with all the ways a request can be made and
all the process boxes. Then you draw a
future state map. What do you want
it to look like? And then, you determine how
do you get from here to here? By identifying problems you're
going to solve, so that then, when you do that, you have
a new current state map. And then, you start
all over again. It's continuous. And you tweak it some more,
and some more, and some more. When you do particularly
A3, value stream especially but particularly A3,
it involves anybody who has anything
to do with that A3, any department has
to be at the table when you do the A3
problem solving. You cannot solve a problem and
then tell another department, this is what you're going to do. They'll totally turn off,
but if they're part of it, they come up with some
amazing-- and I'll show you some work
that we did where some amazing creative
things happened. And Matthew May-- we use-- what you have here,
this is the A3 form that we use to do a problem. Matthew May says, if you can't
fit your problem on one page, you haven't really
done your thinking about what the problem is. And sometimes, I'll start
doing an A3, and it's too big. And then I realize I have to
do we call it the [INAUDIBLE].. And then we break it
down into smaller ones, because you really want to
dig into that problem to get to root cause and fix it. You're going to hear
more about A3 later. So that's a two-day
workshop for me that we do. And my corollary
to all of this is if you ask the right
questions, the answers will usually come easily. It's knowing how to ask
the right questions to get to root cause, really
important, and not going off on these tangents. You heard about the
Jefferson Memorial, but I'm going to tell
you a little bit more in depth about this,
because it's a true story. The Jefferson Memorial
was having problems with cement falling,
and they were worried it was going
to injure tourists. Because it's part of the
National Park System, every monument has a manager. So the whoever was
doing the investigating went to the manager
and said, why is this cement falling here? We have other monuments in the
area, the Lincoln Memorial, the Washington Monument,
all around the same age, all made with basically
the same material. They don't have a problem
with the cement falling. And the manager said, well, the
reason the cement is falling is because the cleaning people
are washing it all the time. And the soap is mixing
with the jet fuel from Reagan Airport, which
is right up the river. And we think that
the jet fuel is causing the soap
and-- the combination of the soap and the jet fuel
to cause the cement to corrode. So he said, we either
need to move the airport or change the soap. So whoever was on this
investigating team said, wait a minute. Let's go ask the people who are
doing the work what's going on. So they went to the
cleaning people. And they said, you're
cleaning this really often. Why? And they said, because there's
pigeon poop everywhere. It looks really bad. We have tourists. So they brought in a bird
expert, an ornithologist, and said, why is there
pigeon poop here, not in the Lincoln Memorial,
not in the Washington Monument, but here? And the bird expert
looked, and he said, it's because the pigeons are
coming to eat the spiders. So then, they brought
in an entomologist or whatever spider
people are called. And the spider people--
person looked and said, the spiders are
here, because they're coming to eat the midges,
these little gnats. And he said, and the gnats
hatch along the river. They don't have a
very long half-life. They hatch in the afternoon. They fly around. They lay eggs. The eggs are fertilized. They have a little
fun time frolicking. And then right around
dusk, they die. And they're attracted to light. So these little midges
saw these lights at the-- Jefferson Memorial
floodlights came on. And they would fly there,
and they would frolic, and then they'd die. And then, the spiders would
come to eat the midges. The pigeons would come
to eat the spiders. The pigeons poop. The cleaning people
were washing. And the cement was falling. What they found out was
the lights on the Jefferson Memorial were coming
on an hour earlier than any of the
other floodlights on the other monuments. So what did they have to do? Change the timing of the lights. So this is the importance of
getting to root cause analysis, really getting to root cause,
because the initial reaction was we just need
to change the soap. So when I work with people, and
they're going off on tangents and coming up with ideas without
doing root cause, I would say, you're changing the soap. Be disciplined to go through
the steps of A3 in the order they're presented, and it will
lead you to the right answer. If you jump to a solution,
it may or may not be the right solution. So be really careful about that. Front line workers can do A3's. They're easy to teach. They allow the organization
to experiment more, get faster results,
because they're doing small projects every day. Learning occurs in
the course of work. It generates ideas,
and those ideas can start to be
clusters of ideas. And A3's can be
organization changing. How do you select topics? A lot of times, from
the value stream map. Sometimes, you just observe,
and you see a problem. And you say, let's
do an A3 on that. Identify specific
issues, and then you just prioritize and begin. It's a view with a microscope. It's drilling down
into variation. It's documenting
problem solving. And it tells a story visually. So on an A3, you'll have words,
and you'll have pictures. It satisfies the people who
are very right-- left brain who want to see words and numbers. It satisfies the people
like me who are right brain and want to see visual. So it's a combination of both. And Taiichi Ono, I love him. He's like my
favorite philosopher. And he was the
president of Toyota. He said, always temper
immediate knee jerk reaction with root cause
analysis, always. Resist drawing conclusions
based on emotions. This is me. I would say, oh,
patients are dying. That was my line all
the time, with why I needed what I needed. Question hearsay and
draw from experience, but be careful
not to rely on it. We always, when we do A3,
use a pencil and paper, pencil with an eraser. There are electronic versions. Save them for later,
because if people start doing electronic versions,
it becomes like a video game. And they're not really paying
attention to the content. Focus on problem solving. And also, if I do
an A3, and I'm going to go meet with the blood
bank, and I bring my A3 ideas on paper with pencil
and eraser, it clearly gives them the message that we
can change this if we need to. If I put it in
electronic version, it almost gives a message,
please try not to change it; I spent a lot of time on this. So pencil/paper,
really important. I know that sounds
crazy, but it works. It's a non-threatening tool. Here's your A3. I'm just going to go
through this very quickly. You have it in front of you. And the left side is all
current state information. The right side is the
equivalent to PDSA, or PDCA. So we always deeply understand
the rights-- the left side. And I'll show you how
to do that before you go to the right side. In my classes that I teach,
I make them fold it back. And no one is allowed
to touch the right side until the left side is totally
complete, because if you don't follow this incrementally
with discipline, you're going to wind
up changing the soap. So this will lead
you to where you need to go if you have
the discipline to do it. Let me show you one. And so you'll see on the left
side the first category's issue. Always state the issue through
the eyes of the customer or the patient when you can. So here's an example. This was one that one
of my clients did. The issue was they had
fiber optic endoscopes that weren't available
when they needed them, because they were either
broken or being repaired. Problem, that's the issue. The next area is the background. It's like, why is this an issue? So explain why it's an issue
if you have some measurements, like 50% of the time or two out
of four cases this happened. Put that here. So in their background about
the fiber optic endoscopes, they said from--
in one year's time, they spent $48,400
repairing and replacing fiber optic endoscopes. That's a lot of money. In the current condition,
you draw a picture, stick figure, no rules. Just draw a picture of
what the problem is. You don't have to be Picasso. So what they drew is
here's the patient. Here's the doctor. Here's the cart with the
endoscopes and big questions, looking for the endoscopes. Once you draw that
picture, you go back and you add storm clouds. What's wrong with the picture? Endoscopes are broken when
they're slammed in drawers or dropped on the floor. Bingo! Anesthesiologists are
searching for endoscopes. They don't know--
excuse me-- if they're clean or dirty, because they're
put on the top of the cart. That's scary. And there's a potential
danger to patients. So once you have
your storm clouds, you can combine some
of them that are alike. Then, what happens is you
take those storm clouds, and they drop down into the
problem analysis section. And each one becomes the
topic for A3 problem solving. So you're chipping away
at what the issue is here. Now, they combined
some of theirs. So in the problem
section, problem analysis, you're going to ask the
what's called five whys. Keep asking why until
you get to root cause. You may only have
to ask it twice. You may have to ask it 10
times, but you keep going. One of the things that I learned
when you ask why is we indent. The anesthesiologist
wastes time searching for fiber optic endoscopes. Why? Because fiber optic endoscopes
are not always available. For me, before I ask
the next why, I say, why are fiber optic
endoscopes not available? Because they're broken
when they're slammed in drawers or drawers. Why are they broken when they're
slammed in drawers and drawers? Because there's no
designated place. You know you have
a root cause when you have an actionable item. There's no designated place. On the other side, we're going
to make a designated place. So you indent your whys as you
follow that train of thought. Now there's a second
train of thought under the anesthesiologists
wasting time. Why? Because they're placed
on top of the cart before and after procedures. Why? Because there's no way to tell
if they're clean or dirty. Why? Because there's no
designated location. So sometimes, your root causes
can come out to the same thing. Sometimes, you have
different ones. And then, it's a
danger to patients, that storm cloud from
above, because there's confusion as to which
ones are clean or dirty. Why? Because there's no
designated location for cleans and dirties. See what's happening here? You've got your
driver for what you're going to do in
your countermeasure on the other side. Root causes are actionable. And most of the time root causes
are because of violation rule number one, not
specified how we do it. I would say 80% to
90% of the time that's why you have a problem,
not been specified. So once you complete the left
side, you go to the right side. Do not jump to the right
side, because the left side is giving you information. Stupidity is having an
answer for everything. The left side gives
you the answer. Wisdom is having a question. The left side forces you
to ask those questions. Remember, thousands of people
saw the apple fall, but only Newton asked why. We need to start asking why. So here's the whole
A3 that they did. This was a real one. They had their counter--
their root causes over here. They drew a picture of what
they wanted it to look like. And they put fluffy
clouds about what's good about this new picture
that what they wanted was a cart that had two
separate places for endoscopes, clean and dirty. On the external part of the
cart, they had dirty and clean were identified. They saved money. And it was safer for patients. So the countermeasures--
how do you-- what are you doing
with these root causes? They were going to put two
tubes on the side of the cart and identify clean and dirty. They also had the
contextual processing on how they would keep
those tubes clean. Once you have your
countermeasures identified, what's the plan to implement
those countermeasures? What's going to happen? Who's going to do
it, by what date, and what's the outcome
accountability? Then, you also have to say,
OK, if we do this project, what is it going to cost? And if we do this project,
what are the benefits we're going to get out of it? Because that's how you sell
this to an administration. Then, how are you
going to test it? So they decided they were
going to test it for-- on one cart for a couple of weeks. The first day they
retrofitted the cart, all the other anesthesiologists
wanted the same thing. They didn't want
to wait two weeks, because it was just brilliant. And the follow-up was
for the next six months, they had zero broken
fiber optic endoscopes. That's A3 problem solving. Where can you use it? Use A3 thinking to do
specific problem solving. If you're doing a redesign
of a department or process, you can use it. You can document changes
for regulatory bodies. I like this for capital
equipment requests. Do an A3 and tell me what
your current state is and why you need it. You can use it to run a meeting. What's the issue? What's the background? Let's get to some root cause
and then come out with a plan. Facility design is being--
it's being used a lot now to redesign new facilities. And it's endless what
you can use these for. Here's an ambulance coming
in with a trauma patient. Problem-- I've got
two trauma patients. And look at the mob
of people there. And if I had sound, there's
all these people talking, and there's incredible
noise and cacophony. It's horrible. This is my scene. I've got a problem. I have trouble
moving these patients through the department. So what we did was
we did-- again, this is a different emergency
department from what I showed you-- the requests for the service
and then the actual service. In this department, they decided
to have three process boxes-- the trauma assessment
and intervention, moving them out to
imaging, and then coming back to the
ED for disposition-- and then disposition. So that didn't look too bad,
pretty simple value stream map. But then we started adding data. And holy mackerel. Look at this data. You're dying three hours. Then, you have to wait 37
minutes till the transport's ready to take you to X-ray. Then you get to X-ray,
and it takes over an hour. Then you wait again for them
to bring you back to the ER. Then you wait again for the
docs to make a decision. And then you wait for the bed. So they decided that there
were a bunch of things here-- I can't see this. Can this go down a
little bit lower? AUDIENCE: No. SUSAN SHEEHY: OK. What we did then was we said
we know we have a problem here. We don't know what it is. So we had to go
back in and look. We did more observation. And what we found is there were
too many people in the room. There were no defined roles
of the people in the room. We had missing equipment. There were lots of students. We love students, but
they were taking up space. So you couldn't move. Poor documentation, poor
communication between the OR and the ICU, delays in getting
O negative blood, John and Jane Doe patients that we couldn't
do anything with until they were registered, X-ray delays. So all of those things
dropped down and became topics for A3 problem solving. And we systematically
went through this, and waiting for an X-ray
read became a topic for A3. Slow decision making
became a topic. We had 14 A3's that we
were going to do with this. And they involved all
different departments. This is what we wanted
it to look like. So I said, why does a patient
come from ED into imaging and then back to ED? Make a decision in imaging, so
they can go right to their bed. So what they wanted it to
look like was time in the ER, time in imaging, go. They wanted it to be under 60
minutes here, under 10 minutes here, for a total
time of 70 minutes. That was their
future state plan. How they were going to get
there, we didn't know yet, but we were going to deal
with those 15 or 14 A3's. And these were all the good
things about this new map. So you have a vision about
where you want to go to. So I know you can't read these,
but I just want to show you. This was registering a John and
Jane Doe patients, one topic. Here's the patient. The picture was
here's the patient, blood pressure 70 over 40. They're bleeding to death. Big stop sign. Because they don't
have a hospital number, we can't get X-rays,
lab, blood, or CT. And here's the nurse
[INAUDIBLE] out there trying to find out the patient's ID. And here's a tombstone. I love dramatic pictures. The patient's going to die if
we don't do the right thing. We put in storm clouds about
what's wrong with this picture, did root cause analysis. We worked on this A3 with
legal and the admissions and registration
people and the ED together and came out with a
plan for preassigned trauma numbers. You didn't have to have a name. If you came in and you
didn't have a name, you became trauma 101, and
you had a piece of tape on your head. And every single thing that we
process for you was trauma 101. Then, when we found out your
name, we merged it with it. So it worked really well. This is one with too
many people in the room. So we had to figure
out what to do. We wanted to have a team. We also wanted to figure out
what to do with the students. So part of the process was
to limit the number of people in the room by team
assignment and then have the students-- there was a
classroom right down the hall. We mounted an overhead
camera over the top, so that they could see and
hear what was going on. They liked it
better, because they said they could see
better, real time, watching the trauma patient. And we were able to get it
down to five or six people most of the time. Everybody brought their
buddies with them, though, when there was a trauma. We also had issues
with overhead page when a trauma was coming in. So we did away with that,
because the whole world would come, because
they wanted to see. Yeah? AUDIENCE: Don't you have
a privacy issue with that? SUSAN SHEEHY: With what? AUDIENCE: [INAUDIBLE] SUSAN SHEEHY: Yeah. We actually met with
legal about that. We didn't videotape them. The students were
allowed to be there. And so the room was
locked, and they signed a privacy agreement. And then, every once in a while,
we would tape the scenario, and we used it at
morbidity and mortality rounds, which is legal. It's not discoverable
in court, and then we destroyed the tapes afterwards. So we met with the
legal department to give us advice
on how to do this, because you can do a
lot with teach it-- for teaching purposes. This one was not the right
supplies or equipment in the room. We met with this equipment
people in central stores. And they actually agreed to
put together exchange carts that they would manage,
which was really cool. But because central
stores volunteered to do the exchange carts, we
didn't tell them to do it. It worked really well. Then we wound up having to
have two exchange carts, because one made everybody
still run all around the room. And we decided to divide the
equipment into side A, side B. And they took it
when it was done. They had backup carts. They stocked it. And they recorded
everything they used. We never had missing stuff. O negative blood,
my favorite one, difficulty getting
O negative blood. We had patients who were dying. This was a knife and
gun club community. The blood bank was
across the street. It was closed at 5
o'clock at night. And the nursing supervisor
had to go get a key, and go in, and find the blood. It was a mess. So we sat down with blood bank. And they said, why don't
we put two refrigerators, one on each of
your trauma rooms? We'll bolt them to the floor,
because things had a tendency to walk in this department. We'll put four units
of O negative blood in each refrigerator. We'll put a lock on it. And we will come
every day and check it for an expiration date. And if it's getting close,
we'll put it back into the main. Now, if we went to the
blood bank, and said, we want you to put
refrigerators in our room, we want you to put 4 negative-- 4 units of blood, and we
want you to come and check it every day, they
would say, go away. But because we sat at
the table together, they offered to do this. There were a number of other
A3's about obtaining X-rays and communication breakdowns. And so what happened
after all of this-- it took about six months
of really intensive work-- almost six months to the day,
we had our first trauma patient through in 60
minutes, not 70, 60. And there was a massive
celebration throughout the whole hospital with every
department that was involved in any of these A3's. We sent cakes to
all the departments. They were just-- it
was on the bulletin. It was everywhere. Pretty proud team that
did this together. What we didn't do, and
which we should have done, was tracked outcomes. We did that later. But in this one, we didn't. I'm going to move quick. This is about rental
isolettes in a hospital that had capacity for 12. They usually had an
average of eight. So they had 10 of
their own isolettes. And then, they had
to rent two any time they had like twins
or triplets born. What happened was they rented
the exact same isolettes, so everybody would be
familiar with them. And they didn't mark
them as rentals. So when they were
done with them, they put them in the storeroom. And every day they
stayed in the storeroom, the hospital was paying money
for those rental isolettes that weren't being used. So they spent about $35,000
more than they needed to on rental isolettes. And we do that with bariatric
equipment and Clinitron beds all the time. So they came up with
a really nice method with biomedical
engineering how to do that. Lean for facility design-- I'm going to finish in
a couple of minutes-- this is a new thing for us. In the last year
and a half, we've been getting called by
architects and designers, because in the request for
proposal for new buildings, the hospitals are asking them
to please have a lean component. Most hospitals don't know
what that even means. But they said, we want it lean. So we've been getting calls. So what happens
is we have them-- we work with the
hospitals in advance to identify their current
problem areas, department by department. We map their current
and future states of what they want it to
look like and help them then design their A3's to fix it. And then that information
informs the design team about how to make the design,
rather than making a design and then trying to fit
the work into the design. So we have a process
methodology where we do current state,
interviews, utilization surveys. We identify problem processes
in given departments. We map the states. We do future state. We do A3 problem
solving with them. And then the future state
maps inform the design team. And then the design team
will take that information, create a design. And then they bring a big floor
layout with puzzle pieces. And we allow the staff
to move things around to see how it would work
using their processes. It's pretty cool. And then, some of
the design teams actually do-- rent a warehouse
and do big gigantic real size mock-ups. Here's an example
in the emergency department, a bunch of
problems that they identified. These are the big issues. So let's look at boarding
and how that informs design. So with boarding patients, these
are the A3's that they did. No patient beds, waiting
for diagnostic results, in patient discharge
scheduling was a problem, waiting for specialists,
and equipment availability. So then, with design, we
picked one of those, no beds available. And we then did
some more digging to see how design could
support fixing this based on the A3 they did. So can we consider a
transition to admission unit, do some care centered care, not
everybody has to be in a bed? Can we do teleconferencing
with consultants, because we're waiting
for them to come in? Can we bring the
computer in the room and do a Skype conference
with the patient? Can we do some real
time bed tracking, which wasn't happening? And then, can the design
team also select finishes that led to quicker cleaning? So we take each one step
by step and deal with it. Here's another one with OR. Lots of issues in the OR. Then, the one that
we highlight here is room turnaround
time in the OR is huge. So what are the things
that prevent the room from being turned around? These are all A3's
that we worked on. So let's take the top one. Anesthesiologist is not ready. So how can we inform the
design team about that? Well, because the
anesthesiologist office space wasn't near the preoperative--
the perioperative and surgery suite. The perioperative suite
and the surgery suites were not close together. The proximity-- he always had
to go to the family waiting room, that was not nearby. So how do you design
that so that this person, not a-- a case cannot start
unless this anesthesiologist is in the room. So how do we make the
design make this happen? So this all informs design. It's pretty cool. It's a lot of fun. And the keys in design are
participation from everyone in the staff, valuing
everybody's input. Anything goes in the room. We respect employees,
patients' families, staff across the
board, collaboration between departments. So if we're working
on an OR thing, but it involves an ER
transfer or transport, they come to the table and work
on that same project together. And then, this becomes our
patient, not your patient. And then, a total commitment
from administration. We always do a
report all at the end of each day with
administration present to show them what
they've come up with. And then, empowering staff to
make those decisions, really important. These are just some of
the things we've done. There's thousands of them. But I want to just
show you that it can go anywhere
across the hospital with value stream mapping and
A3's, from med reconciliation to we had problems with DNR
orders, or fast-tracks, or lab turnaround times,
or poor signage, or cluttered halls, wrong
site surgeries, coding issues. We can work anywhere, anywhere. Let the staff tell you
where their problems are. One of the things
that's really important is if you're going to prepare
an organization for culture change, you really
have to prepare the soil for those seeds. So that means working
with senior leadership, we do lots of work
with senior leadership, overview of what lean is. We spend a day just doing
planning for rollout of lean. Who's going to be on that team? Who are the lean champions? You need to make sure there's
some physicians involved. And they're the hardest
group to get involved, not because they don't want to
be, but because of time. And then, who are
the informal leaders? There are going
to be people that start to rise to the
service, managers and staff. So you need a lean coordinator. If you don't have a
lean coordinator who's going to follow up
on these projects and make sure they're working
and make sure people have what they want, it's
not going to work. So that lean coordinator,
or one, or two, or 10, are really important. And instead of telling
people what to do, we're now saying no one knows
this job better than you do. How can I help you? Different way of thinking. Healthcare has to be a place
where good enough never is. When you ask for change,
though, you need to know, because you have to
be a little bit gutsy to be a lean proponent, make
sure it's change that matters, because change is scary. And a lot of people are not
going to like it at first. And I like this one too. This is an Air Force mantra. If you're taking
too much flak, you know you're definitely
over a high value target. So my advice to you is so when
you're taking a lot of flak, either put your flak jacket
on and stay the course or go choose another project. It's your call. Why does lean fail in hospitals? Lack of leadership commitment
is the biggest one-- when they just hire you
to come in and do it, but they're not committed. Inadequate resources, incomplete
lean education of the staff. This is so important that there
are no expectations placed on the staff that this
is the way we're going to do business from now on. And the absence of teamwork
and the presence of siloes. This is why lean fails. This is interesting. In 2004 Olympics
in Athens, the US 4 by 100 relay teams,
men and women, were projected to be
by far and away better than anybody else in the world. They failed, both teams,
because they were all good at what they did, but
the handoffs were not good, the baton handoff. Missed timing, dropped baton. It's really important to
synchronize those handoffs. No matter how good
you are individually, if your team isn't working
well, it's going to fail. So ending with what
I started with. Matthew may said, lean doesn't
light a fire under people. It lights a fire within people. And it's so exciting
to watch a kitchen worker, or a housekeeper,
or a security guard come up with ideas and be so proud of
the ideas they come up with and own it. And they become a
part of that team. So I challenge you, because Walt
Disney said, why do we do this? He said, it's fun to
do the impossible. And I think that's what
we're facing in healthcare. So let's fix what's
wrong with healthcare. Just to show you, we
do have some resources. If you want to go
to our website, we have some books,
some training sessions. We have some courses coming up. We've got a conference. Please go on the website
and check out anything. And I'll be here. AUDIENCE: [INAUDIBLE] SUSAN SHEEHY: I have
them here if you-- Oh, and if anybody is
interested in a facility design, I brought a few articles. I didn't have enough
for everybody, but it's about St. Anthony's
in Pendleton Oregon and how we did the
facility design there. So if you want them,
I'll just pass them on. AUDIENCE: Thank you, Susan. [APPLAUSE]
