Pulse
Lean Machine
Park Nicollet Health Services turned to a Japanese automaker for a management strategy it says saves money, streamlines services, and improves care.
Dressed in their workday best and standing single file before an audience of co-workers in a large conference room on Park Nicollet Health Services’ St. Louis Park campus, the 11 staff members look a little like a group of children nervously waiting to recite their lines in the school pageant.
Because they’ve exchanged their uniforms this Friday morning for street clothes, it’s hard to tell a respiratory therapist from a receptionist as they take their turns at the microphone. Each has been assigned a part in this “report out.” That’s Park Nicollet terminology for the end-of-the-week downloading of data and ideas to improve the way work gets done in several of the organization’s surgical departments.
One by one, members of the team introduce themselves and explain how they attempted to meet this week’s goal of improving “flow,” smoothing “load,” and creating “standard work” in the surgery department. Sounding more like assembly line workers than health care professionals, they describe how they clocked cycle times, diagrammed traffic patterns, and videotaped processes as shaky images of storage areas and reception desks flash on the screen behind them.
The presentation is the culmination of a weeklong rapid process improvement workshop (RPIW)—one of 180 planned for the year. The workshops bring together people with various backgrounds and skills to scrutinize the performance of a workgroup and solve a particular problem.
What Lean Lingo Means
To understand any conversation about lean production at Park Nicollet Health Services or anywhere else, you need to know a few key terms, some of which are Japanese. Here are a few frequently used phrases and their definitions:
5S: A set of concepts that help organizations ensure a clean and organized workplace. The concepts, each starting with the letter “S,” are sorting, sweeping, standardizing, simplifying, and self-discipline.
Flow: The progressive achievement of tasks so that a product proceeds from design to launch, order to delivery, and raw materials to end product with no stoppages, scrap, or backflow.
Kaizen: Gradual, unending improvement, doing little things better, setting—and achieving—ever higher standards. Park Nicollet’s whole lean effort is called Kaizen.
Lead time: The total time a customer must wait to receive a product after placing an order.
Muda: Any activity that consumes resources but creates no value.
Rapid process improvement workshop: A team of people engage in a rigorous and disciplined process that uses the tools of lean production to achieve immediate results in the elimination of waste.
Standard work: Detailed, step-by-step guidelines for every job in the lean production system.
Takt time: Available production time divided by the rate of customer demand. Takt time sets the pace of production to match the rate of customer demand.
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One of this week’s teams was assigned the goal of reducing the number of instruments on the case carts for the 12 types of urologic surgeries done at Park Nicollet. Previous RPIWs had revealed that roughly 58 percent of instruments on the carts went unused. By getting physicians to agree on a standard set, they report eliminating a total of 1,076 instruments across 12 procedure trays and reducing a typical instrument setup time from 8 minutes to 3 minutes, all of which, they estimate, will save Park Nicollet $273 per case cart.
Robert Wetherille, M.D., chief of surgery, says such a simple change can lead to a series of benefits tangible to both patients and physicians. He explains that because each surgical instrument has to be manually washed, run through a cycle in a washer, and then sterilized in a unit with limited capacity, using a large number of instruments can create shortages that can hold up surgeries. He says it used to be that on some days he’d have to wait an hour or more for a tray of instruments to get sterilized. “That doesn’t happen anymore,” he says.
The RPIWs are a key feature of a Toyota Motor Corp. management strategy called “lean production” that Park Nicollet began implementing about three years ago. The goal of lean production is to reduce effort, inventory, space, and time in order to become more responsive to customer (ie, patient) demands and produce higher-quality products (ie, care).
Going Lean
Park Nicollet CEO David Wessner embraced lean’s less-is-more strategy several years ago after talking with J. Michael Rona, president of Seattle’s Virginia Mason Medical Center, which was the first health care organization to try Toyota’s quality-improvement methods. Wessner liked what he heard and saw. And he thought the approach might be a good fit at Park Nicollet, which had already tried such quality-improvement programs as Six Sigma and found them unsatisfactory.
Wessner wanted to find a way to get a lot of people involved in improvement and allow them to make rapid changes, “to let the people on the frontlines of health care effectively improve health care,” he says. He wanted to both cut costs and improve quality. His proposal to his management team in 2003: Let’s go lean.
Park Nicollet tested the waters in its endoscopy department. The chair of gastroenterology had informed Wessner that they needed to stop recruiting gastroenterologists because they were out of space in the department. After an RPIW, the staff realized that the endoscopy department could double its patient capacity using the existing space and by adding physicians. By making a number of changes, physicians could see more patients and spend more time with each one. “We had it all wrong,” Wessner says. “We thought that the facility was the constraint. Actually, we had plenty of capacity.” One of the changes that had the most impact was the implementation of “waterfall” scheduling, which means that patients trickle in every few minutes rather than arrive in rushes, causing bottlenecks for receptionists and nurses and long waits.
Although Wessner hesitates to reveal how much Park Nicollet has spent on lean, he estimates the total is well into the millions. The organization signed a five-year contract with the consultants who had helped implement lean at Boeing and then Virginia Mason and made lean training mandatory for its leaders.
Quick-Change Artists
Park Nicollet Health Services CEO David Wessner says the most beneficial aspect of the rapid process improvement workshop (RPIW), the centerpiece of lean production, is that it makes work processes visible. “What this does is expose the work and the waste, lets everybody see it,” he says, “and then frees people, giving them a way that they can actually take action on it.”
In an RPIW, about a dozen people with various backgrounds and who do various jobs descend on a work unit to time activities.“You can’t time something that you’re not observing very carefully,” Wessner says. “Then as you chart it out, others can see and understand what you’ve seen.”
RPIW members then map traffic patterns, diagram floor plans, and take pictures of both things and people to identify waste in the process, physical obstacles, and unnecessary steps that are often integrated into workplace systems, yet are invisible to workers.
The team presents its recommendations to other staff at the end of the week, with the final product being an agreed-upon set of procedures and recommendations for changes that might range from tearing down a wall to changing a software program.
Those changes are implemented right away, says Jeremiah Whitten, a Park Nicollet spokesman. “If a wall is in the way, you knock down the wall,” he says. “The whole point is that it happens immediately.”—C.P.
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So far, 133 Park Nicollet employees have earned or are on track to earn certification. Wessner himself got trained, a process that takes about 18 months, requires attending classes and reading several books, and includes a visit to factories in Japan and Seattle, where participants don steel-toed shoes and goggles and try to put into practice what they’re learning. And Wessner did something else. To get physicians on board, he committed to paying their salaries so they could train and participate. “That’s what it costs to have physicians participate,” Wessner says. “There’s no other way to do it.”
Doctors on Board
That decision directly affected David Homans, M.D., chief of cardiovascular services, who initially had to be won over to the idea that what had been done in another industry and country might be applicable to health care in Minnesota. By the time he was on a factory floor at the Genie forklift plant in Seattle, he was convinced that lessons from industry could be applied to health care.
“We walked onto this production line, and the first thing the workers said was, ‘You know, our big problem is all the special orders.’ … When you present this stuff to doctors or nurses, their first response almost always is ‘But all of our patients are different.’ Here we had the workers at this plant telling us that that was their problem, too,” he explains.
Then, when Homans traveled to Japan last year to witness how lean works at Toyota’s Yamataki plant, he saw further parallels between manufacturing and health care. Japanese workers said they wanted to be like surgeons and have all the tools they needed at hand. “They were borrowing that concept from health care,” Homans says. In addition, he was impressed with the complexity of the assembly workers’ jobs. One woman made 75 different kinds of circuit boards. “In my practice, I don’t see 75 different kinds of patients,” he says.
Now an advocate for lean, Homans not only admires Wessner’s “guts” for launching the movement, he defends the strategy before his peers. It’s important other doctors get involved in the process, he insists, explaining that if they don’t, they won’t understand it, and if they don’t understand it, they’ll be threatened by it. So far, more than 100 physicians have participated in lean projects, according to Wessner.
Homans believes lean’s focus on speed, efficiency, and consistently high quality makes sense to many physicians. “Much of what we do is very time-sensitive,” he says. He notes that cardiologists, for example, see the importance of having the patient flow from the front door of the ER to the cath lab, where a stent can be put in place. “We need to make that go as fast and as consistently and perfectly as possible,” he says. “That’s really what lean is all about. No wasted time. No wasted effort. No wrong steps.”
Mixed Response
Surgeons’ opinions about lean remain mixed, according to surgery chief Wetherille, one of this week’s RPIW team members. “It’s been stressful for the staff. It’s been stressful for the surgeons,” he says of the series of RPIWs they’ve done over the past two years. These programs have already led to remodeling of the surgical facilities, a decision to reduce and standardize the number of tools surgeons use for various procedures, and changes in the way patients are prepped for surgery, where family members wait, and what doctors do when.
Wetherille’s job following the morning’s report out will be to send a letter to his surgeons informing them that the RPIW has resulted in a new series of steps they’ll need to take following each operation. Wetherille knows some physicians won’t receive the letter with open arms. “As you would expect, there are surgeons who are cynical about things and skeptical,” he says. “But we’re starting to see enough positive gains with these efforts that we’re breaking down skepticism and turning people into believers.”
It doesn’t hurt that Park Nicollet’s lean strategies were written up in The Lancet in January or that the organization reported saving $7.5 million in 2004 and $5.4 million in 2005 as a direct benefit of RPIWs. “The big dollars have come from increased capacity,” Wessner says.
Such evidence may win over the remaining skeptics. “It’s not perfect,” Homans says. “But as a care strategy and organizational business strategy, it makes more sense than anything else we could think of. And the challenges facing health care today are such that not changing is not an option.”
Wessner likes to compare Park Nicollet’s early experience with lean techniques to that of a sixth-grade orchestra. “It’s more a commitment to the future than music,” he says.—Carmen Peota