The Lean Methodology in Healthcare: Implementation, Improvement & Measuring Success

[Dr. Wolfgang Stehr]
I was maybe not very clear on how we put together the team and how we decide on the team. Usually there is a Lean expert, there's a person who understands the Lean methodology, who understands the different process steps. They already do a lot of groundwork before the Lean event actually starts. They review and interview all the different groups of people who may be involved in the process. There's the OR tech, there's the OR nurse, there's the person from central processing or sterile processing, and there are the surgeons. Not particularly this one, but in some Lean improvement workshops, we actually included the parents because we wanted them to be at the table to say this is what better would look like for us. You have the whole team and that team then comes together and we did sometimes two or three days of workshops in a row where on Monday we would say, "All right, this is our goal, this is what we're working with. Let's go out and look at the workplace, look at the place where the work is actually done and see what the reality is. How this equipment is being used, how this equipment is being stored, and who all touches this equipment in real life."

We're not trying to take a problem, take it out of the work area and move it into some back office and try to fix it in the back office. One of the key elements of Lean is you have to go look and see where the work is being done and that's where you're going to improve it, and that's where you're going to fix it, because otherwise, it's always people bringing their story or their part of the story into an office and you never get the whole story.

[Dr. Gopi Shah]
That makes sense. How important, in this situation, was it also to-- did you need to get hospital buy-in or any administrative level buy-in for something like this?

[Dr. Wolfgang Stehr]
Yes, because we take a few people offline and they are not doing their job. They're doing improvement work. Hospitals who engage in Lean methodology, they know that it takes the investment of taking folks offline to do this work in order to make improvements. In an ideal Lean world, about 3% of your workforce should be involved in Lean work. Sometimes that's a small portion of nurses that do a few hours so that over the year, maybe that's about 3% of their time. That's the investment the organization has to make. We were lucky we had an administration that embraced that process. They wanted this and they wanted us to be safer and better and of course save money.

[Dr. Gopi Shah]
No. That makes sense. In terms of having the Lean expert there to guide the process, who is that? Is that the chief quality officer of the hospital? Is that an external third-party consultant? How does that work?

[Dr. Wolfgang Stehr]
For most organizations, it starts with a consultant, and they come from the outside. Then they start to train people on the inside and ultimately the process can be run on the inside. I became trained to be a Lean expert and physician champion in the organization. After a few years of doing it, I was able to run the workshop, help prepare the workshop, but then it really also is helpful to have a Lean office because they then can help with the sustain, they can help gather the data, they can help see what impact did this actually make. There's multiple elements. Training people on the front-line to own the process is much more helpful and then feels much more natural because we've all experienced this. Some consultant comes, they don't know the organization that well, they don't know you that well, they don't know your processes that well. They start with asking a lot of questions. You already have the answers, so you don't really need them because you are the one who has the answers.

[Dr. Wolfgang Stehr]
Great. That's a really important question because we can only improve what we can measure. In this particular process, we looked very hard to see what are things that would actually show that we are doing better. We had three different measures. The first one was, can a nurse or a tech put this thing together so that it works? The second one was, how long does it take to put the equipment together? The third one was, how many drawers do you have to open in order to put this equipment together? The opening of the drawers in this big metal cart was a surrogate of how efficient is it put together.

When we started, I walked around and I asked 10 nurses, I said, "Hey, please put together a bronchoscopy set for a one year old kid." I had my stopwatch and I clicked and I watched them do it. It would take them 10 minutes. Out of 10 nurses, one was able to put this together, and they had to open an average of about 10 drawers, because you open the first one, it's not in there, you close it, you open the next one and it's still not in there, you open the first one again and finally you find it. Those were the three things. When we started, it took a long time. The ability of actually creating a functional setup was almost zero. Numerous drawers had to be opened.

[Dr. Gopi Shah]
Can the staff put it together, how long does it take, and how many drawers, how did y'all pick those as your outcomes to measure?

[Dr. Wolfgang Stehr]
It was hard to say, oh, how much money can we save when we do a better job because there's no dollar sign on your drawer. You sometimes need to really look and see, okay, what is a surrogate measure of time or a surrogate measure of success in order to look and see whether you're doing is better or not, because then on the back end, where we arrived, was I asked 10 nurses whether they could put it together and all 10 of them were able to put it together. It took 2 minutes and they had to open zero drawers. That was an improvement.

[Dr. Gopi Shah]
Then how often do you feel like people need training in putting the equipment together, because again, this isn't a high volume, this isn't doing tonsils, 10 tonsils in a day, 5 tonsils a day, and 10 tubes. They're frequent enough, but they're not once a week. How often do you have to train?

[Dr. Wolfgang Stehr]
Very important that you talk about education. The people who are engaged in the process, in the workshop, they know what to expect and they know, "Oh, we're doing this differently now." There are other people who have to touch it. There are other people who have to touch the equipment and so an important part of every kaizen workshop is a education plan. On the education plan, you have, what do people need to be educated on? Who are those people? You write them down by name. It's like, all of our 15 central sterile processing department technicians need to know, all of our nurses need to know, these are their names, and this is the person who is responsible to train them.

Then you go around and you check the box, you say, okay, this person was trained, they can do it to be somewhat proficient at it, and this person, because they work in the ENT room every day, they are an expert at it. You actually know, okay, these people need to be trained, these people were trained, and then most important thing, you write a document that is called a standard work document. Standard work can either live with the equipment or can live in sterile processing or can live in the operating room, where if you have a traveling nurse who knows nothing about your organization, they open the folder on standard work and in there they will find, this is how we use and put together bronchoscopy equipment, they can look at it, sometimes there's photos in it, sometimes there's drawings in it, so that even if they know nothing about your organization, they know nothing about pediatric bronchoscopy, they can still put it together.

[Dr. Gopi Shah]
In the moment, this folder is easy to use with a few minutes of understanding in the moment because I can't imagine that being on day one of orientation of the traveling tech or nurse for a procedure they may or may not have to experience.

[Dr. Wolfgang Stehr]
Exactly. That's another very important element of Lean management, which is making things visual. We call it visual management, so that the ENT cart doesn't have this tiny little three letters in the corner, ENT cart. It should be bold, it should be clear, it should have the right color. It's like, this is the ENT cart. Then you may have either a folder or some laminated sheets hanging on the side and you can pick it up and on there it's like, bronchoscopy. Then you look it up and all the information you need, how to put it together, is in there. Same with the equipment. We're going to talk about that in a minute, I guess. The equipment will be managed differently, so people can really visually quickly understand this is the ENT cart, this is how I do a bronchoscopy. They look through the drawers or the trays and then they see, "Oh, this is bronchoscopy."