Lean is a topic that has interested me since I had the pleasure of meeting and speaking with Cindy Jimmerson, founder and President of Lean Healthcare West. Cindy, the author of several books, is passionate about Lean and has experienced tremendous success in bringing Lean to hospitals.
But why haven’t we seen much of Lean in physician practices? I think the reasons are simple:
- Staff in medical practices are already running very slim, and the labor of additional projects may be difficult to take on
- Larger businesses such as hospitals mean higher potential for returns – physician offices may not see significant bottom line changes from Lean reduction of waste compared to revenues from new procedures or partners
- Physicians are not early adopters of management theories and may find it difficult to see the ROI in Lean
Although Cindy Jimmerson says that every hospital she has worked with has more than earned back the program costs through successful Lean projects, it may be a hard sell to most private physicians who see their incomes shrinking year by year.
An excellent article in the Healthcare Quarterly,12(3)2009:32-41 by Longwoods Publishing gives a concise yet meaningful discussion of Lean and describes Lean projects and outcomes in several hospitals. Healthcare Quarterly focuses on “best practices, policy and innovations in the administration of Canadian healthcare” and is edited by Dr. Peggy Leatt, University of North Carolina, Chapel Hill.
Even if your practice won’t be hiring a Lean consultant in the forseeable future, understanding more about Lean has the potential for enhancing your efforts at improving processes in your practice, or maybe even encouraging you to pursue Lean leadership training.
What follows is an except from the article “Leading Lean: A Canadian Healthcare Leader’s Guide” by Benjamin A. Fine, Brian Golden, Rosemary Hannam and Dante Morrasome, which gives some basic Lean terminology:
Lean Terminology: What Does It All Mean?
Lean: A term coined by those who compared Toyota’s methods to those of other manufacturers: “Lean is the antidote to waste … It provides a way to specify value, line-up value-creating actions in the best sequence, conduct these activities without interruption whenever someone requests them, and perform more and more effectively” (Womack et al. 1990; Womack and Jones 2003).
Value-added work: Work that adds value from the perspective of the client or customer; it is the kind of activity or service for which end users are willing to pay. In healthcare this could be the taking of blood for a medically necessary test or patient time spent with an examining physician.
Waste or muda: Activities of overproduction, waiting, transportation, processing, inventory, movement and defective products. Type 1 muda represents activities that cannot be avoided immediately given current policies, assets and technologies. If a physician cannot eliminate the need to fill out a drug allergies form because of an existing policy, that muda is categorized as type 1. In contrast, type 2 muda is clearly wasteful activity; it is the prime target for immediate elimination. An example of type 2 muda is the time that staff spend looking for equipment that isn’t stored or categorized in a sensible way. This wasted time can be immediately removed by re-organizing storage areas – for example, moving blood pressure cuffs to one standardized location so they can be easily found.
Value stream map: Visual presentation of activities required to bring a service or product from customer order to delivery. Value-added steps and muda are most easily identified on a value stream map. The mapping starts with defining what the customer demands (in the top right corner) and then captures all the steps required to fulfillment. The “current state” value stream map represents the steps as they exist today. The “future state” value stream map is a visual representation of an idealized state. Improvement activities (like kaizen events below) undertaken by front-line staff move the process toward the future state.
Gemba: In Japanese, gemba means “actual place.” In the Lean context, it refers to the place where value is actually created: the shop floor in manufacturing, or a clinic (e.g., emergency department, outpatient dialysis unit, or operating room) in the healthcare setting. The concept of gemba is important because it emphasizes the Lean principle that value – what customers actually want – is created on the front lines, not in boardrooms. The value stream mapping exercise forces workers to “walk the gemba” to see value and the process that creates it.
Kaizen event or rapid improvement event (RIE): Kaizen means “improvement” in Japanese, and kaizen events are focused on implementing improvements to the process of meeting customer demands. In healthcare, these week-long events provide the opportunity for front-line workers from different disciplines to work together to rapidly plan, implement, measure and adjust improvements.
Kamikaze kaizen: Kaizen activities that improve an isolated segment of a process but negatively affect the entire process are referred to as “kamikaze kaizens.”
If any readers out there have experienced Lean in your hospital or medical practice, please share by leaving a comment.
The Centers for Medicare & Medicaid Services (CMS) have become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.
Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found here or here.
Nextgov.com’s Bob Brewin reported June 8, 2009 that the Military Health System (MHS) has added social networking tools to its web portal serving 1.4 million people on active duty. The social networking tools are designed to connect with the 18-24 year-old demographic which makes up a large portion of the active duty personnel.
In addition to MySpace, FaceBook, and Twitter, Brewin notes:
The agency also uses sites such as YouTube to reach to the younger age group with videos on subjects ranging from prosthetic legs to golf therapy clinics for combat wounded veterans to a short profile of an occupational therapist who works with combat-wounded veterans.
The video on prosthetic legs had the most views last month. The second-most-viewed video was a 2008 video on the Bataan Memorial Death March at White Sands Missile Range, N.M., which features Army medic Staff Sgt. Matthew Sims, an indication that troops crave more than just medical information. Kilpatrick said MHS posted 66 videos on YouTube in May, with the top five viewed 3,785 times.
The portal has been available for about two years, but the Twitter feed was just launched in March.
The MHS web portal is impressive as is their stated mission: The Military Health System mission is to provide optimal Health Services in support of our nations military missionanytime, anywhere.
In March 2009, PBS’s documentary program Frontline aired “Sick Around the World”, a look at healthcare in five capitalist democracies: the United Kingdom, Japan, Germany, Taiwan, and Switzerland. The documentary attempts to answer the question “What can the US learn from these countries?” In addition to watching the documentary online, you can read the transcript, or order the DVD ($55), and the website includes interviews, discussions, a teacher’s guide, reading and links, analysis (The Cost of Drugs Issue is enlightening) and more.
Also tale a look at “Sick Around America” from Frontline.
Statement to the press by WHO Director-General Dr Margaret Chan
11 June 2009
World now at the start of 2009 influenza pandemic
Dr Margaret Chan
Director-General of the World Health Organization
Ladies and gentlemen,
In late April, WHO announced the emergence of a novel influenza A virus.
This particular H1N1 strain has not circulated previously in humans. The virus is entirely new.
The virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30,000 confirmed cases have been reported in 74 countries.
This is only part of the picture. With few exceptions, countries with large numbers of cases are those with good surveillance and testing procedures in place.
Spread in several countries can no longer be traced to clearly-defined chains of human-to-human transmission. Further spread is considered inevitable.
I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.
On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met.
I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.
My personal list of new employee orientation best practices has been shaped by my experiences in private practices as well as hospitals. Every organization has different resources to draw upon, but each group has core goals that must be fulfilled by a good orientation:
- completion of paperwork including federal and state W-4s, I-9, direct deposit and benefit elections
- emergency contact information (included in hospital employee health intake)
- orientation to the organization, including designations, specialties, departments, sites, affiliates and an organizational chart
- completion of mandatory annual training such as safety, standard precautions, and HIPAA
- mechanics of name tags, parking tags, lockers, keys and codes
- signing off on understanding and agreement to confidentiality, compliance and personnel policies
In addition to these core goals, critical information to be shared during this time should minimally include:
- personnel policy review with emphasis on important (typically abused?) policies
- code of conduct/ shared basic competencies (mission and values, professionalism, communication, chain of command)
- computer security (passwords, internet policy, protection of PHI)
- workstation ergonomics and patient lifting policy (sadly lacking in many medical practices)
Important training that is rarely covered:
- Customer service (what is it and how do we measure our success or lack thereof?)
- Cultural sensitivity and diversity training
- Non-clinical employees’ role in medical emergencies
- Personal safety (coming in early or leaving late, patients threatening staff by phone or in person)
- Expectations for the first 90 days (training, communication, questions, problems)
Making Orientation Memorable
I hope that I am fortunate enough to have been missed by my readers while on an unintentional sabbatical these last several weeks. I have been moving to my new home in North Carolina and starting a new job. Our house temporarily has no television, no land line, no cell phone reception and no internet access so Ive been cloistered from the news, my blog, Twitter, LinkedIn, email, FaceBook and listservs. It has been INTENSELY quiet, if there is such a thing.
Ive been doing a lot of thinking about my new community, my new job and my chance for a fresh start. A television commercial I saw recently says something about being able to be more yourself where no one knows you. Its true. Here in my new community I can be a better me as no one knows any different. A new job is always an opportunity to do things differently and Ive made a list for myself of the things I will do differently, better, or not at all:
1. I will stop rolling my eyes. I dont like it when someone rolls their eyes at me, yet I think I roll my eyes without even realizing it. I will become aware and stop it.
2. I will arrive to meetings on time. I have the compulsion to do just one more that compels me to read one more email, squeeze in one more phone call and so I dont arrive places on time. Its rude and it sends the message that I think my time is more valuable than the time of others. Nope.
3. Ill work a normal amount of hours per week, as soon as I can find out what that is. Boy, is this a can of worms. Ive always heard that you have to put in more hours if you want to advance and that managers should be the first ones in the office in the morning and the last ones to leave. The problem is, of course, that you will be exhausted, sick, cranky, unfocused, estranged from your family and one-dimensional if all you are is a workaholic. It is a disease and I want to be on the road to recovery.
I have lots of new stuff to share. For one thing, I just completed the best orientation Ive ever had, and several readers have expressed an interest in creating a stronger orientation program for their practices, so Id like to expand on this. I also kept extensive notes on my job search process and will write about searching for a job in 2009.
As always, I thank you for coming along for the ride with me and I welcome your comments and feedback.