Improving Health Care Quality and Safety

Transcription

1 Doing More with Less: LEAN THINKING and Patient Safety in Health Care Foreword by Helen Zak, Lean Enterprise Institute Improving Health Care Quality and Safety

2 Doing More with Less: LEAN THINKING and Patient Safety in Health Care Senior Editor: Project Manager: Manager, Publications: Production Manager: Associate Director: Executive Director: Joint Commission/JCR Reviewers: Robert A. Porché, Jr. Jan Kendrick Diane Bell Johanna Harris Cecily Pew Catherine Chopp Hinckley Laura Botwinick, Rick Croteau, Linda Hanold, Linda Murphy-Knoll, Paul Schyve, Frank Zibrat Joint Commission Resources Mission The mission of Joint Commission Resources is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education and consultation services and international accreditation. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of the Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission publication should not be construed as an endorsement of such organization, product, or services, nor is failure to include an organization name, product, or service to be construed as disapproval by the Joint Commission on Accreditation of Healthcare Organizations Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), has been designated by the Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from the Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois permissions@jcrinc.com ISBN: Library of Congress Control Number: For more information about Joint Commission Resources, please visit ii

3 TABLE OF CONTENTS Foreword v About This Book: Lean Thinking: A New Quality Approach vii Acknowledgments ix Introduction Background The Importance of Performance Improvement Chapter 1: Origins of Lean Thinking The Roots of Lean Thinking Lean Comes to the United States The Five Steps of Lean Implementing Lean Thinking Beyond Manufacturing into Health Care and Other Service Industries Other Quality Systems Chapter 2: The Five Steps of Lean Thinking Step 1: Specify Value Step 2: Identify the Value Stream Step 3: Flow Step 4: Pull Step 5: Perfection Chapter 3: Applying Lean Thinking to Health Care Using Lean s Five Steps to Provide Health Care Leading Lean: Effective Leadership in a Health Care Organization Getting Started: Identifying Priorities Getting Started: Mapping the Value Stream Adding Nothing but Value: Cutting Organizational Waste iii

4 Doing More with Less: LEAN THINKING and Patient Safety in Health Care Chapter 4: Meeting the Challenges of Lean in a Health Care Organization Common Challenges of Lean Implementation Solutions to Lean Implementation Challenges Becoming Lean Chapter 5: Case Studies Pittsburgh Regional Healthcare Initiative Works to Perfect Patient Care Cancer Treatment Centers of America at Midwestern Regional Medical Center Applies Lean Thinking to Pharmacy Processes ThedaCare, Inc., Fosters a Culture of Change Appendix A: Lean Leaders Appendix B: Using Lean Principles to Meet the Joint Commission s Standards Appendix C: Selected Resources Glossary Index iv

5 FOREWORD The Lean Enterprise Institute (LEI) receives numerous phone calls and s from people in hospitals and other health care organizations asking, Do the principles of lean thinking apply to my work, and if they do, how do I implement them? The answer to that question is in this book. Doing More with Less: Lean Thinking and Patient Safety in Health Care does more than affirm that lean thinking principles apply to health care. The Joint Commission has produced a practical, focused book that explains to health care professionals in their own terms how and why lean thinking applies to the crucial issue of safety. Beginning with an overview of how lean thinking developed and spread in manufacturing, the book quickly and most important for the health care reader clearly explains why lean thinking principles are at home in health care. Even better, Doing More with Less offers specific examples of how to translate the principles of lean thinking into the health care environment, and how leading hospitals are using the concepts to improve safety by eliminating the root causes of problems. For instance, one hospital incorporated into its safety program the lean thinking concept of halting a production line when a problem appears in order to resolve the problem immediately. Staff members were trained and empowered to stop the process when a problem occurs, quickly assess the situation, and solve the problem at the source. If staff members cannot fix the problem right away, they call for help. This is just one of many examples in which Doing More with Less takes a principle from an industry that looks very different to health care professionals and shows how it applies in their field. The key to seeing the connection, as LEI Founder and President James Womack often points out, is that all businesses are collections of processes. Successful industrial, service, or health care companies are those that manage core processes, the series of actions that must be done correctly in the correct sequence at the right time to create value for customers. Successful lean transformations also require the active involvement of company leaders. I was encouraged to see the emphasis that the book places on the role of leadership, including a checklist to help leaders determine their strengths and weaknesses in promoting change. The v

6 Doing More with Less: LEAN THINKING and Patient Safety in Health Care book offers many other practical resources a concise glossary of lean thinking related terms, lean thinking related Web sites, and information on how to use lean principles to fulfill the Joint Commission s performance improvement standards. I hope that readers of Doing More with Less will take the ideas in this book and use them to become brilliant process thinkers and leaders who will transform health care and continuously improve the safety of their patients. Helen Zak Executive Vice President and COO Lean Enterprise Institute vi

7 ABOUT THIS BOOK Lean Thinking: A New Quality Approach Many health care providers are finding that a method using lean principles, which, translated to health care, would emphasize patient service, safety standards, improved quality, staff satisfaction, and economic vitality, is the answer. Based on the Toyota Production System introduced in Japan, the lean system may be the answer to a health care organization s mandate to do more with less. Lean thinking is, indeed, doing more with less less human effort, less time, less space, less equipment while providing patients with exactly what they want when they want it. That description sounds simple, but to work efficiently, lean methodology must take into account some rather complex ideas. A primary concept underlying lean thinking is the elimination of waste. In fact, proponents of lean thinking, not only in Japan but everywhere, use the Japanese word for waste muda when discussing any activity that uses resources but creates no value. In this context, muda is anything that creates mistakes, stockpiles unnecessary inventory, requires unnecessary process steps, moves employees from one place to another for no logical reason, forces workers to wait for an earlier snag to be fixed, or produces products/services that do not meet the demands of the customer. It is obvious, therefore, that waste has no place in the lean thinking processes. The rationale behind eliminating waste is that, by so doing, an organization can carry out the task of providing the customers/patients with what they want when they want it with the minimum of resources. vii

8 Doing More with Less: LEAN THINKING and Patient Safety in Health Care The result is a performance improvement method that, from the standpoint of a health care organization, identifies the patient as the central focus and fashions its methods of operation to create an environment driven by the values surrounding the patient. These values include patient safety, patient satisfaction, and appropriate patient care. This is not to say that other factors are unimportant. As with many health care operations, there are two sets of customers : the external customers the patients, payers, and suppliers and the internal customers the staff and the organization. Interestingly, when the principles of lean thinking work to meet the needs of the primary customer the patient the results often also meet the needs of the staff and leadership of the health care organization. That would seem logical, given that a goal of lean thinking is to provide more value for the patient while using fewer resources. This can translate into cost savings (wasting fewer resources) and staff job satisfaction (providing more for the patient while eliminating waste and inefficiency and fostering staff satisfaction by permitting rewarding valued-added work). Subsequent chapters offer a detailed description of lean methodology and how it can be applied to health care organizations. Specifically, Chapter 1 provides an overview of lean thinking and brief comparisons to other quality systems. The overview presents the origins of lean thinking and explains how the system began as a manufacturing system that is still used in industry. There is also a brief list of lean-specific terms whose meanings are essential to understanding the system. Chapter 2 lays out the full concept of the lean system by describing the steps involved in the lean process in detail. This chapter is meant to be a reference chapter to which the reader can return for information about lean methodology in general, as well as about how it pertains to health care situations. Chapters 3 and 4 apply the processes of lean methodology to the health care industry in specific ways. One of the most important topics in these chapters is the role of leadership in implementing lean thinking in the health care environment, and Chapter 3 devotes a significant section to this subject. Developing value-creating activities and meeting the challenges of their inauguration into a health care organization are explored thoroughly. Throughout, the end goals of patient safety and quality services remain the reference point for all activities. Chapter 5 presents case studies from several organizations that are applying lean methodology in their institutions successfully. These organizations vary in scope and size, but all have used and/or adapted principles of the lean process as a performance improvement tool. Finally, there are three Appendixes at the end of the book. The first, Lean Leaders, offers short biographies of several leading advocates of the principles behind lean methodology. Using Lean Principles to Meet the Joint Commission s Standards presents specific performance improvement standards and describes how lean s concepts apply to each of them. The third Appendix, Selected Resources, lists lean-related printed resources, references, and related Web sites for additional information. viii

9 ABOUT THIS BOOK: Lean Thinking: A New Quality Approach Note: Throughout this book the terms customer/patient and product/service are occasionally used to indicate that lean methodology can be applied to both manufacturing (customer, product) and service industries (patient, health care services). The terms are used as a way to indicate that lean thinking is not just a manufacturing performance improvement tool. In a health care setting, the definition of customer is not as clear-cut as in other industries; the health care customer can be a patient (the primary customer), a payer, a supplier, or a governmental/regulatory agency. For the purposes of this book, the patient referred to is the primary customer, who receives the care and services of the health care organization. Acknowledgments Joint Commission Resources is grateful to the many reviewers and organizations that have greatly enhanced the quality and scope of this unique book with their contributions. Special thanks go to Robert D. Charles, CEO of North Star Advisors, a lean health care consulting firm; Chet Marchwinski, Communications Director, Lean Enterprise Institute; and Diane Miller, Director, Institute for Healthcare Improvement, for their contributions. Special thanks are also due Ann Kepler, for her efforts and dedication to delivering a high-quality manuscript. ix

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11 INTRODUCTION Waiting 10 hours simply to receive one chemotherapy treatment is not the way to spend one s time. Yet that is how some cancer patients used to spend one day a week during the chemotherapy phase of their care. A typical treatment day began in the hospital lobby, where the receptionist directed the patient to the sixth-floor lab for blood tests. Leaving the lab, the patient traveled to the second floor to meet his oncologist. As a rule, the lab work was not ready so the patient would wait until it arrived. After the physician reviewed the lab results and examined the patient, the patient went to the eighth-floor treatment center. After yet another wait, he received the intravenous chemotherapy he had come in for several hours earlier. By the time the patient left the hospital, he had spent 8 to 10 hours at the hospital during which, if he was lucky, he managed to find some time for lunch. He was exhausted as well as annoyed, but he had resigned himself to tolerating the inconvenience in return for the benefits of the treatment. Today, chemotherapy at this hospital is no longer a daylong event. Inspired by the success of the lean thinking methods of the Japanese automotive industry, specifically the Toyota Production System, Virginia Mason Medical Center (VMMC) in Seattle, Washington, has applied lean concepts to a variety of situations in the hospital, one of which is the cancer treatment procedure. One of lean thinking s key concepts is that the value of a service is defined from the perspective of the customer in this case, the patient. Another is elimination of waste. In this chemotherapy program, VMMC reviewed the process from the cancer patient s perspective and looked for waste in the treatment procedure. The outcome was a streamlined process that worked to everyone s advantage. VMMC began by consolidating its cancer facilities in one area of the hospital. The physicians offices and lab are adjacent to the exam and treatment rooms. A pharmacy has been installed within the cancer center, accelerating chemotherapy preparation time. The centrally located waiting rooms include windows, an Internet café, and attractive furnishings to ease patient stress. The patients proximity to their physicians offices 1

12 Doing More with Less: LEAN THINKING and Patient Safety in Health Care further reduces stress. The physical layout of the cancer center is designed so that everything flows to the patient. Thus, patient time and energy, both of which cancer patients guard, are reduced. The new system cuts four hours from a patient s treatment day, and the saved time has allowed the hospital to treat more patients each week. VMMC is among the health care organizations today that are continually searching for better ways to provide quality health care while maintaining or improving the intrinsic health of their own organizations. VMMC and many other organizations have found that the principles of Toyota s lean thinking methodology can be applied to organizations outside the manufacturing sector to achieve individual quality goals. Background A renewed endeavor to improve health care performance began in the mid-1980s in the wake of American industry s realization that to compete globally it must use a new approach to improve performance. Rather than relying on the traditional method of inspection, industry chose to focus on doing a proper job the first time that is, industry executives tried to understand the processes their organizations used and then continuously improve the design of those processes. This approach has been attributed to W. Edwards Deming, known as the father of the Japanese postwar industrial revival, and to the Japanese companies, including Toyota, that adopted Deming s philosophy as a daily business program. 1 (See Table I.1.) Around the same time, many health care organizations began using this improvement approach. Health care leaders were looking for a way to make significant improvements in clinical outcomes, as well as in financial performance as a response to the critical need to manage costs. Many health care leaders liked the idea, borrowed from industry, that teams of patients and health care providers could work together to evaluate current performance and to improve processes. The need for this type of redesign of health care services was inevitable. Changes in the health care industry in the past two decades have mandated changes in delivery of services to achieve both quality care and financial stability. As the population ages, people are living longer often as a direct result of improved health care technology and procedures and the number of patients is dramatically increasing. At the same time, the need for physical space and improved turnaround is becoming critical. The expense of updating technology, the costs in both equipment and in acquiring resources for training, is continually spiraling. In short, health care providers are being asked to serve more patients with fewer resources at lower costs. At the same time that health care organizations are forced to do more with less, they are facing more public scrutiny. While capitated care, with its emphasis on cost containment, continues to be an important factor in health care economics, patient safety, care quality, and 2

13 INTRODUCTION Table I.1 Deming s 14 Points 1. Create constancy of purpose for continual improvement of products and service to society, allocating resources to provide for long-range needs rather than only short-term profitability, with a plan to become competitive, to stay in business, and to provide jobs. 2. Adopt the new philosophy. We are in a new economic age, created in Japan. We can no longer live with commonly accepted levels of delays, mistakes, defective materials, and defective workmanship. Transformation of Western management style is necessary to halt the continued decline of business and industry. 3. Cease dependence on mass production. Eliminate the need for mass inspection as the way of life to achieve quality by building quality into the product in the first place. Require statistical evidence of built-in quality in both manufacturing and purchasing functions. 4. End lowest tender contracts. End the practice of awarding business solely on the basis of price tag. Instead require meaningful measures of quality along with price. Reduce the number of suppliers for the same item by eliminating those that do not qualify with statistical and of the evidence of quality. The aim is to minimize total cost, not merely initial cost, by minimizing variation. This may be achieved by moving toward a single supplier for any one item, on a long-term relationship of loyalty and trust. Purchasing managers have a new job and must learn it. 5. Improve every process. Improve constantly and forever every process for planning, production, and service. Search continually for problems in order to improve every activity in the company, to improve quality and productivity, and thus to constantly decrease costs. Institute innovation and constant improvement of a product, service, and process. It is management s job to work continually on the system (design, incoming materials, maintenance, improvement of machines, supervision, training, retraining). 6. Institute training on the job. Institute modern methods of training on the job for all, including management, to make better use of every employee. New skills are required to keep up with changes in materials, methods, product and service design, machinery, techniques, and service. 7. Institute leadership. Adopt and institute leadership aimed at helping people do a better job. The responsibility of managers and supervisors must be changed from sheer numbers to quality. Improvement of quality will automatically improve productivity. Management must ensure that immediate action is taken on reports of inherited defects, maintenance requirements, poor tools, fuzzy operational definitions, and all conditions detrimental to quality. (continued) 3

14 Doing More with Less: LEAN THINKING and Patient Safety in Health Care Table I.1 Deming s 14 Points (continued) 8. Drive out fear. Encourage effective two-way communication and other means to drive out fear throughout the organization so that everybody may work effectively and more productively for the company. 9. Break down barriers between departments and staff areas. People in different areas... must work in teams to tackle problems that may be encountered with products or service. 10. Eliminate exhortations. Eliminate the use of slogans, posters, and exhortations for the workforce, demanding Zero Defects and new levels of productivity, without providing methods. Such exhortations only create adversarial relationships; the bulk of the causes of low quality and low productivity belong to the system, and thus lie beyond the power of the workforce. 11. Eliminate arbitrary numerical targets. Eliminate work standards that prescribe quotas for the workforce and numerical goals for people in management. Substitute aids and helpful leadership in order to achieve continual improvement of quality and productivity. 12. Permit pride of workmanship. Remove the barriers that rob hourly workers, and people in management, of their right to pride of workmanship. This implies, among other things, abolition of the annual merit rating (appraisal of performance) and of Management by Objective. Again, the responsibility of managers, supervisors, foremen must be changed from sheer numbers to quality. 13. Encourage education. Institute a vigorous program of education and encourage self-improvement for everyone. What an organization needs is not just good people; it needs people that are improving with education. Advances in competitive position will have their roots in knowledge. 14. Top management commitment and action. Clearly define top management s permanent commitment to ever-improving quality and productivity and their obligation to implement all of these principles. Indeed, it is not enough that top management commit themselves for life to quality and productivity. They must know what it is they are committed to that is, what they must do. Create a structure in top management that will push every day on the preceding 13 Points, and take action in order to accomplish the transformation. Support is not enough: Action is required! Source: Deming W.E.: Out of the Crisis. Cambridge, MA: MIT Press, 1982, pp Used with permission. 4

15 INTRODUCTION service are becoming priorities. Patients, health care providers, purchasers, payers, community leaders, accreditors, regulators, and others stakeholders are evaluating health care organizations and demanding accountability as never before. In the past, making quality and cost information available to the public, as well as to everyone giving, receiving, and paying for services, was optional. This is no longer the case. The Internet provides health information and competing health care facility data to anyone with access to a computer, and the stakeholders demand full disclosure. Only by being transparent about quality, effectiveness, and cost containment can a health care organization remain a viable institution. In addition, intense competition within the health care industry is pressuring organizations to improve performance and increase quality while simultaneously decreasing costs. Health care organizations are being compelled to identify and emphasize value, which is based on the relationship between the perceived quality of an organization s service and the cost of that service. Note the use of the term perceived quality; not only must a health care organization provide value but it must also provide a means of recognizing and identifying that value. This is part of the transparency that health care consumers expect today. Along the same lines, health care regulators and accrediting bodies are seeking objective, comparative information with which to assess health care providers performance. Thus, health care organizations are focusing on gathering and analyzing processes and outcomes data and then using these data to (1) make improvements where needed and (2) ascertain whether certain procedural changes accomplished proposed goals. To do this, health care professionals look for performance improvement tools that help them do the following: Set priorities Plan improvement goals Work effectively in teams to improve processes Identify and understand the organization s existing processes Select and implement procedures to improve processes and their outcomes In addition to facilitating overall performance improvement, there are often specific reasons why a health care organization decides to choose a new quality approach. The previous or current quality system is not providing the means to meet the leadership s objectives. The organization is failing to compete in the marketplace. The organization is trying to recover from or prevent a crisis. 5

16 Doing More with Less: LEAN THINKING and Patient Safety in Health Care Table I.2 Symptoms of a Flawed Health System in the United States External Nearly 100,000 Americans die each year from medical error. Seven percent of inpatients will acquire a hospital-related infection. One of every 100 hospitalized patients will receive the wrong medication. After spending millions of dollars to develop a new drug, it is administered correctly and to a patient who will benefit from it only 30% of the time. Chances of dying from avoidable human error are 10,000 times greater in a hospital than in an airplane. Internal Forty-one percent of U.S. nurses are dissatisfied with their jobs (30% to 40% internationally). Thirty percent of nurses younger than 30 plan to leave the profession within the next year. Thirty-three percent of nurses report sufficient staff to meet workload. Forty-five percent of nurses believe that the quality of care has deteriorated during the last year. Thirty-four percent of nurses believe their patients can manage their own care when discharged. Source: Thompson D.N., Wolf G.A., Spears S.J.: Driving improvement in patient care: Lessons from Toyota. JONA 33:586, Nov Used with permission. The composition of an organization has changed for example, a consolidation of several health care providers into a regional organization to provide a continuum of care to patients in a defined geographic region and to compete for managed care contracts. The administrative leadership has changed. These challenges, along with the increase in public scrutiny of health care services, have made high-quality health care more than just an ethical imperative; providing good health care has become an operational necessity. The Importance of Performance Improvement The changing health care scene has provided incentives for health care leaders to search for approaches to improve health care services and to compete in the marketplace. These approaches must have workable systems and measurable outcomes. To achieve quality performance, they should be patient centered and emphasize patient safety and satisfaction. They 6

17 INTRODUCTION should engender enthusiasm among staff members and be flexible and capable of modification as necessary. As performance improvement approaches changed to meet changing needs, that is, to provide a means of continuously improving processes, leaders in health care uncovered a number of important lessons: Leadership must commit to continuous improvement both by approving necessary resources and by actively participating if the effort is to succeed. Organizations must involve their patients both internal and external and fulfill their needs and expectations. Most opportunities for improvement occur by identifying and correcting problems within the processes with which individuals work and not by identifying individuals who are not performing well. Many work process problems arise from handoffs or transfers of projects between people or departments. Accurate and reliable measurement is necessary to assess current performance and to target areas for improvement. A systematic improvement method is necessary to guide measurement, assessment, and improvement. Although any of these reasons may become an impetus for a change, there is also a downside to this kind of monumental change. Although improvement in quality performance often does lead to a savings in costs, making a change in quality systems can itself be costly, particularly at the beginning. There is the cost of training and the cost of time in implementing a new system, and there is always the risk of failure. Overriding all these potential obstacles is the resistance to change. Later chapters will explore these problems and possible solutions within the health care industry. Reference 1. Leadership Institute, Inc.: Who Is Dr. W. Edwards Deming? Updated May 26,