You know the type. Their iPhone calendars are impeccable. Their day begins on the treadmill, includes scheduled email times and ends with periodical reviews at 10pm. They know their destination and have mapped the best route by time of day. These people are living LEAN, and achieve sustainable levels of success with each move toward perfection. While not always practical (or enjoyable) in our personal lives, this mindset is critical for business success in today's globally competitive environment. (Incidentally, Congress could learn a few lessons as well) As an industry, the American healthcare system falls into three groups; those that embraced LEAN principles early and persevered, those that tried and failed and quit, and those that are just waking up (better late than never). While the ACA and other reform measures are shifting incentives and establishing penalties in the marketplace, too many major healthcare organizations are taking the easy way out and laying off hundreds if not thousands of associates. While some layoffs may be necessary, there are still opportunities for new business models and deeper internal LEAN efforts for providers to thrive once again.
Recognizing this, most hospitals have begun the LEAN process improvement stage to eliminate waste, reduce travel distances and minimize inventory, with varying levels of success. A few have begun LEAN Six Sigma, fine-tuning standard deviation measurements to the nth decimal point. However, decimal points will only get you so far; process improvement begins and ends with the people. Significant improvement is dependent on successful communication, widespread engagement and serious commitment, on every level, starting with the administrative suite. These are the things that make LEAN not just a buzzword, but an answer to healthcare woes.
Fine-grain process mapping
LEAN process mapping begins with a large brush and broad strokes framing the continuum of care. However, the real art of improvement lies in uncovering the detail of each patient interaction and choreographing an optimal customer experience. Staying with the artistic analogy, a LEAN effort begins with a Contemporary canvas but quickly moves to the Impressionistic period, with a fine-grain focus on each small dot comprising the whole. The current process should be dissected in sequential, layered process meetings beginning with front-line staff and working through clinical staff, nurses, and providers. It is tempting to dive right into optimization, but these meetings should focus on current processes. Only by thoroughly understanding the current system, with all of its barriers, bottlenecks, and missed communications, can you truly begin to optimize it.
Having multiple disciplines and generations present in these meetings allows tenured employees with multifacility experience to interact with new recruits untainted by traditional structures and sacred silos. The most successful meetings generate a series of lightbulb moments, as different groups realize that specific steps, handoffs, or processes are unnecessary. A clerk may realize that information collected earlier in the patient interaction is very similar to data being requested by another department. A non-clinical staff member might question the need for a second surgical staging area, sparking a cost–benefit revaluation. These "aha!" moments among team members encourage tangible action as employees take ownership of making their process leaner.
No care delivery change can come without physicians' participation and engagement. For consultants and administrators, the new mantra might be to keep your patients close and your physicians closer. Physicians need a seat at the head of the table, early on in the process. Ideally, physician engagement begins with individual 30-minute interviews, concisely framing issues and respecting the physician's time. Change is not easy- on one recent engagement, a primary care physician pleaded to return to paper records. We all understood his frustration; the interim decline in productivity was measureable. However, there is no long-term advantage to "going back"- technology is here to stay. Early physician buy-in will such changes a bit easier as you work to push paradigms and test the status quo.
Determination to Innovate
Perhaps most crucially, leadership must embrace and communicate the magnitude of change before us. Board members, physicians, and staff must understand America's dire healthcare situation. The message delivered at the kick-off, and consistently over the next several years, must demand:
commitment –additional time and energy will be needed to see this through
courage – a "just do it" call-to-action to deliver consistently superior service
confidence – freedom to acknowledge and learn from mistakes without reprisal
Leadership at all levels must be determined to innovate and recognize the potential value of new processes and responsibilities. For example, hospitals experiencing unacceptable ED wait times should consider empowering triage nurses with appropriate protocols and authority to order diagnostic testing and redirect patients to results sub-waiting areas. While some might balk at this transfer of authority, the results can be significant. When physicians first see these mid-to-low level acuity patients, they are armed with lab and imaging results, allowing a solid percentage of quick dispositions and reducing throughput by 30 minutes on average.
Organizational dedication to innovation will be particularly important as the Affordable Care Act phases in. Evolving payment structures, such as bundled payment reimbursement, will no longer require provider-patient physical proximity, making telephone and online visits a viable, cost-effective alternative that could free up physicians' offices for acute care and hospitals for critical care. Leaner processes can pave the way for early adoption of such innovations and can also help hospitals cope with reimbursement reductions associated with ACA mandates.
To truly do the LEAN process justice, a hospital needs to commit to each one of these components- communication, engagement and innovation. Put more simply, they need take LEAN out of the boardroom and put it into action on the front lines. Anything less is a disservice to employees, patients and the healthcare industry as a whole.