A Midwest hospital CEO knew that in order to get his organization delivering better results for patients; he and his management team would need to lead a transformation. He had experience with Lean methodology, yet despite good initial results, performance seemed to erode over time. And as Don Berwick, former CEO of the Institute for Healthcare Improvement, has said, the current system was perfectly designed to get the outcomes they were getting.
We worked on two fronts: building senior management’s capability to foster adaptive
problem solving throughout the hospital and to develop the capability to coach hospital resources for spreadig the concepts.
We guided senior management to incorporate a scientific approach to problem solving
into their own work. Together, they tackled resource issues as well as taking a unit out
of service while still meeting patients’ needs. We also developed a lean engineer and an
organizational development person to coach units throughout the hospital.
After the first 12 months, the hospital saw improvements in staff engagement scores, decreased absenteeism, lower ALOS and cost per adjusted patient day and reduced drug costs in the pharmacy. Importantly, the work continued after R4 staff left and the hospital succeeded in coaching all departments and units throughout the hospital within the following 12 months. Over that period, the prior trends were sustained as well as additional results such as: 0 falls with injury, 0 HAPUs, and decreased supply costs.
The flagship hospital in a 12-hospital system completes its preparations and goes live on a new clinical information system. Staff complain about the new system. Docs refuse to use the CPOE functionality. Productivity drops. And a few safety and privacy problems occur as a direct result of the system and its implementation. The corporation decides to delay the upcoming implementation at two large community hospitals.
We observed the current state of training and preparation. Preparation was too focused on "system functionality," rather than being connected to real work.
We trained a group of superusers to do three critical things: lead improved standard training activities; lead groups of associates to improve their work--in a way that optimized the benefits of the CIS; and provide post go-live support and training to users, focused on optimizing work practice and system function.
Post go-live special support reduced to 2 weeks--as opposed to the unsatisfactory 9 weeks for the previous implementation. Productivity "dip" after go-live reduced to 7 weeks from 14 months. CEO sends email to all associates asking, "how can we build on the momentum?"
The nurse manager in a 36-bed medical unit is continually urged by the Quality staff to get her pneumonia vaccine number up. The unit had been consistently performing at about or below 70% for both the pneumonococcal and flu vaccine screening and administration as indicated.
The Quality Director was feeling the pressure from management due to public reporting requirements and pay for performance.View Graph
The unit’s manager and charge nurses were beginning to learn about problems by observing. They observed their existing pneumonia vaccine process and we helped them prototype and redesign their process. They moved the assessment from discharge to admission and developed the new process in a day.
The unit proceeded to test and redesign their prototype as nurses indicated confusion or problems. The prototype went through almost 20 small redesigns as the process went from unit to unit in the hospital.
Pneumonia vaccine assessment went from < 70% to > 97%. Staff learned about how to improve the prototype to fit their work. At one point, a staff RN told the quality director that although a proposed redesign seemed logical, she was unlikely to do it consistently because it did not fit how she worked.
She and the quality director redesigned that version of the prototype together. Another nurse told the quality director that she would have never thought of one of the problems they encountered until it happened with one of her patients that day.
Three years ago, after many years as a successful tech, Cindy became manager of a radiology department. Her performance since then has been lackluster: CT down times have increased over the last few months cutting into volume. The radiology department, however, is still reasonably sound financially and Cindy occasionally shows the brilliance she did as a tech. In addition, Cindy is likeable and a great cultural fit in the organization. Cindy's boss John isn't sure what to do.
We gave John, director of radiology and Cindy's boss, a framework with which to work with Cindy for two hours per week for six weeks to diagnose and treat what was ailing her.
Through their working together John discovered specific problems that Cindy was struggling with: she needed remediation on budgeting and staffing activities, she was frustrated that staff weren't solving unit operational problems, she was spread too thin on committees that didn't directly impact her department.
Rather than seeing Cindy as "all talk" or as a troubled manager, John was able to help Cindy on specific areas in which she needed to improve. In turn, Cindy improved CT second next-available time, staff and doctor engagement scores increased and volume increased through productivity improvement (no new costs.) All of this was the result of focused practice and coaching on Cindy's weaknesses.
Small community hospital worried about losing physicians and revenue to nearby competitors because operating inefficiencies were costing physicians time and money. They needed to improve their operations so that physicians don’t take their patients and their revenue to a competing hospital. They were also hoping to get their medical staff more engaged and solving problems at the hospital rather than moving to a new hospital.
First we engaged the physicians to ensure that we were working on the issues that troubled them most. We interviewed physicians and attended their meetings to verify what they had shared with us individually. From this we were able to verify that their biggest concerns were on-time starts in the OR, and turn around time for imaging reports. We then worked with staff in the OR and Radiology departments. We trained staff to identify problems and test solutions and we worked with the management of these areas to support Lean process improvement ideas.
Start times for the first case of the day (the one for which you have the most control) improved from 43% to 67%. We were also able to identify and share with the docs that most of the remaining incidences of cases not starting on time were cased by the physicians. Turn around time for diagnostic imaging improved from a 61 hour average to a 12 hour average. This improvement in imaging also spilled over to their mammography wait times with went from 49 days down to 5. Perhaps more important than the improvements themselves, was how they were done; involving physicians and staff so that the physicians were collaborating with the hospital and the results were sustained.