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Making Care Systems Leaner and Safer


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Making Care Systems Leaner and Safer

By Tom A. Augello, CRICO

Related to: Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

Hospitals begin using an automotive process to root out errors.

Guest Commentators

    • Dorothy Goulart, MS, RN; Brigham and Women's Hospital; Boston, MA
    • Linda Bacelis-Bush; GE Healthcare Performance Solutions; Milwaukee, WI
    • Terry Clemmer, MD; LDS Hospital; Salt Lake City, UT
    • Zeev Neuwirth, MD; Atrius Health; Newton, MA


    At Brigham & Women's Hospital in Boston, Dorothy Goulart works year-round to help departments and clinical units do more and less at the same time. Taking a page from Toyota's manufacturing model, Goulart is among a growing army of health care professionals working to drive out waste and inefficiency in the health care industry—using Lean Processes.

    "Lean" is a method for fixing system flaws by using some key concepts: first, the front-line people at the point of care are involved to identify problems and potential solutions, or "counter-measures"; then, they examine every step in a single process—or pathway—across multiple settings and professional disciplines, called a "value stream"; select specific metrics to measure success; assess the intervention against the metrics; and repeat the process routinely to continue to root out inefficiency and waste. Standardizing processes is also an important Lean concept.

    According to advocates, "Lean" promises to cut costs, add to staff satisfaction, and reduce medical errors at the same time. Dorothy Goulart:

    "We can improve the way that we provide care. Toyota talks about error proofing processes so that errors don't occur in the first place. So it's really very applicable to looking at various processes proactively to see ways that we can keep errors from ever occurring in the first place or trapping them, you know, actually identifying them, seeing them before they ever reach the patient."

    As the Director of Performance Improvement at Brigham and Women's Center for Clinical Excellence, Goulart has overseen the use of Lean for a variety of projects. Driving out waste and improving efficiency frees clinicians to do more of what they are uniquely trained for. Goulart says these principles that increase efficiency can also mean reduced nosocomial infections, fewer drug errors and other patient safety benefits.

    "We've done similar work using Lean principles looking at medication reconciliation. So how might a physician at the end of an office visit with a patient actually have a process of making sure of what the patient says they are taking for medicines match the list of medications that is in the patient's medical record so that everyone is aware and is on the same page as to what medicines the patient is actually taking?"

    At LDS Hospital in Salt Lake City, Dr. Terry Clemmer is Director of Critical Care Medicine. Dr. Clemmer was part of a research project that applied "Lean" to his ICU. They still use Lean principles…but he identified some challenges.

    "Some things are very successful. The routine task of delivering potassium or running a ventilator, ambulating patients according to protocols and things. Those have been very successful. We struggled more with things that cross into other departments, although we are making good strides right now. But for sepsis, for example, where you have to coordinate the emergency department, which is an integral part of this, along with the laboratory and the pharmacy and everybody to get it done, those have been much, much more difficult because we cross into territories where they are not as committed."

    A key concept in Lean is that the process is embedded throughout the organization. In addition to the jobs they were hired to do, staff get trained in identifying problems in real time, designing metrics for improvement, coming up with countermeasures, and repeating the process. Dr. Zeev Neuwirth is Vice President of Quality and Innovation for Atrius Health, a multi-group primary care practice network in the Boston area. Dr. Neuwirth was able to use some early small-scale successes with "Lean" to show senior leadership the value. Now it's starting to spread at Atrius.

    "You can just keep on doing process improvement after process improvement, but if it's not connected to your middle management level and those goals and if it's not connected to your senior management level and the goals that are there, it's really not going to do much good. And so what we've done is we've created an entire kind of operating platform, if you will, that goes from the top of the organization to the frontline of care and at each level there are metrics, the so-called five true north metrics, and there's literally a cascade and a linking of the metrics and to make sure that we're all working in alignment. That is a radically different approach which very, very few places are aware of, much less doing."

    Dr. Neuwirth has used Lean for a number of safety projects at Atrius. He says that clinicians can be skeptical, but they quickly learn that Lean is more than a flavor of the month. Dr. Neuwirth says the highest use of "Lean" will often lead to dramatic changes in work-life, that actually make providing care more rewarding. He points to efforts in the Orthopedics Department at one of his practice sites.

    "When you walk into Orthopedics now at our Kenmore practice, you'll see in the Orthopedics Department two or three white boards up on the wall. If you come at 8:30 in the morning and at 3:30 in the afternoon, every single day, Monday through Friday, you'll walk into a team huddle. So every morning and every afternoon, they have a team huddle, and every morning and every afternoon their review of the metrics, these balance score card metrics, and they go over each one of them to see how they've done that day and then they go and review the week, and see how they're trending in terms of over time if they're getting better or worse or staying the same with these metrics. They also then move to a problem board. So if they are not getting the metrics or if they are not improving on any metrics, they actually do a root cause analysis and they figure out what's going wrong and how to fix it quickly. And so you're walking into a work environment that is a real learning organization."

    Goulart says that at the Brigham, a number of skeptics have become converts to Lean—and even its strongest advocates—after being involved. They see that their own ideas for what's wrong and how to fix it are respected, that they get to set the goals and implement their own changes and are supported by leadership.

    Goulart and the Brigham use a healthcare consulting arm of General Electric—GE Healthcare—for help implementing Lean at the hospital. Linda Bacelis-Bush is the consulting manager for GE Healthcare Performance Solutions, which has worked with institutions across the country and the UK. At the Brigham, Lean takes the form of 4-day, rapid-cycle style improvements, one-day "work-outs" for a specific problem, and Lean training classes for individual leaders. But the long-term goal is for as many people to use Lean as often as possible.

    "Especially with Lean, it's not something you can just learn in the classroom. You can learn some of the fundamentals, theories of it, but there's no match for actually going out, participating in a project, and seeing the results of the staff being involved, identifying what the problems are, identifying what the potential solutions are, trying them out right away, seeing the result."

    According to Bacelis-Bush, those victories are important to show management and clinical leaders that the benefits of Lean process improvement is worth the cost in staff time. Leadership buy-in is a critical success factor to bring down the work silos that allow process breakdowns to go unnoticed.

    "In Lean they talk about value streams. So a value stream could be the service that is provided to a patient, and this patient could go through several different departments in their whole journeys through to get this one health care service. To get the attitude or the collaboration between the different departments within a hospital to see that there is a bigger picture here is a big challenge. It's a huge challenge, and I think Lean is a good way to address that though because there are many ways to be able to come up and look and for anyone whose done any kind of value stream mapping, it's a way to look at the services that are delivered across all of the departments and be able to see the interactions, and then eventually identify the waste and how to make it better across all of those."

    That's been the experience of Dr. Neuwirth's work at Atrius as well. After introducing the Lean methodology, residents began asking to stay and establish their careers there. Dr. Neuwirth says that hadn't happened in 30 years.

    "There were probably multiple factors, but the biggest thing we did and the thing that distinguished it from everywhere else we were working was implementing Toyota Lean. One of the Toyota masters that I had been speaking to about this and mentioning it to him, said, you know, the way you improve people's morale is that you allow them to have a goal, you set a target and you set a goal, and you give them the skills and the tools to actually reach that goal. There's probably nothing more satisfying for a human being to actually create a goal and achieve it. There's something just fundamentally wonderful about that. Again, it's kind of our core to be creative and to set a vision and set a goal and to achieve it. It's really kind of what makes us tick in some respect, and that for me is really at the heart of the Toyota Lean methodology."

    January 1, 2009
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