Lean Nursing Practice Part II

In Part I of this series I discussed what we have done in our clinic to ‘lean’ nursing practices. The last 4 items are smaller but shave minutes every day and decrease the change of having to repeat a task.

Standardized Medical History
Each incoming patient has their medical history reviewed by the nurses. It is an EMR (electronic medical record) and the questions asked are developed in conjunction with the nurses. At one time I worked in a hospital where the nursing history was exhaustive and aspects of it pointless to patients who are admitted for just a day. When developing our own medical history we ask the questions; why do we need this question, is the information provided elsewhere and how many people does it apply to? Like most medical histories, ours is a combination of asking about the disorders that our important to our practice (like cardio-respiratory disease) and ‘shot-gun’ questions that cover all the bases (e.g. “Have you ever been in the hospital”).

Standing Orders for x-rays
Rather than trying to hunt down the doctors for common x-rays on consultation we have standing orders for routine x-rays with agreed upon criteria for repeating x-rays that have been sent by other practices.

Cross Coverage by ancillary services
The nurses’ skills are demanded for complex patients. Other staff will jump in to help when nurses are tied up with a difficult patient for duties that the nurses normally perform (such as organizing which patient is to be seen next, seating patients, simple medical histories).

Emergency Drills
Our clinic practices emergency drills at least once a month in each office. The drills serve two purposes. First is familiarization with infrequently used equipment and procedures. The second is to find broken or missing equipment. There has scarcely been a real ‘emergency’ I’ve been involved in a clinic/ward setting where something is not missing, the best example of which was an emergency tracheotomy where we had the tray, trach tube and local but no scalpel.

Our clinic’s lean six sigma initiatives for nursing are basic but they’ve been effective. If I had to pick one initiative as the most productive it would be decreasing time wasted trying to contact other practitioners’ (doctors) either through a) standing orders b) standardized contact agreements (e.g. phone, page) c) decreasing the need to clarifying orders. For more information a nursing unit in France has published their lean initiative here.

Lean Nursing Practices Part 1

Everdream asked me to blog about Lean nursing practices.

Disclaimer
Our clinics are the equivalent of a ‘surgi-centre’ with both consultative appointments and procedures under anaesthetics. While I’ve been staff at hospitals for years, I have never supervised a floor lean initiative. I have supervised many clinic lean initiatives with our own 20+ nursing staff. For a framework of lean initiatives click here and here and here.

Semantics
Normally I consider initiatives that decrease repetition of a task Six Sigma and initiatives that decrease either the time or variation in time of a task Lean. I think most of us would agree that there is a continuum so all of the listed changes are ‘Lean Six Sigma’.

Goals
Time with the patient
Better Quality of Care

All the nursing initiatives are to increase time with the patient. In our minds, that means defining projects that are relatively small and well defined. They must not create more daily work for the staff. Nurses are not administrators but clinicians. Their time with the patient is at least as important as the doctors.

One of the reasons we never completed ISO9000 was our concern that the paperwork would overshadow the goals of quality improvement. In the same vain, we try not to let lean initiatives distract from the ultimate goal. For instance, endless meetings or daily paperwork that is burdensome are not part of initiatives.

The rest of this blog describes some of the short initiatives we’ve undertaken.

Contacting Doctors
As far as I’m concerned this is the biggest waste of time for nurses. Even in our clinics nurses could spend an hour a day trying to c contact various doctors. In 2002 installed an email server (Exchange) in-house and in 2005 a Blackberry BES Server. The network was necessary and the small additional expense in administration was more than compensated for in nursing time. Now, unless it is urgent, the nurses can simply email the question or request rather than trying to hunt down the doctors. It is not uncommon for me to get an email while talking with a patient from a nurse that is 20 feet down the hall.

When needed for patient in the clinic the nurses also had to search the office to let the doctor know the patient was ready. When we increased the size of the office this had the potential to become a major problem. Now, rather than trying to hunt us down, they will call our desk and if not there page us. Instead of waiting several minutes x 30 patients a day they can move on to the next patient and keep the system flowing.

Equipment:

Sundry Items
The quintessential nursing lean initiative is decreasing how much they walk. I can still remember a friend being asked to wear a pedometer in 1982. We set up each room identically so items are easy to find. We also ‘double stock’ each room with quickly used sundry items (gloves, masks, etc…). Each will have the item in use and a back up. When one runs out they can immediately use the next to save time having to search.

Placing Equipment
When designing our current building consideration was given to the location of the central supply (we are a 20,000 clinic). Central supply houses items used for each case and is centrally located. A supply room holds a weekly supply of materials in the basement.

Broken Equipment
Broken equipment used to go through 2 levels of management before replacement. They would give the part to a supervisor who would give it to the manger who would ok the order. Ironically the nurse was often the one ordering the part anyway. Now the nurses contact the supplier directly and have it ordered for routine repairs. Common items are ECG leads and saturation probes.

Out of Date Equipment
Certain items expire but are rarely used (e.g. defibrillator pads). The expiry date is now kept with the drug expire dates and checked weekly on a checklist

Cost Control
With increased stocking comes an increased cost. Rather than trying to control sundry item cost from the outset we stocked the rooms to maximize efficiency with the patient then re-created our stocking system for ‘just in time’ delivery of most times so that supply costs didn’t spiral out of control. I’ve found this to be a constant battle between preventing a zero-outage and minimizing stock in the basement. It is still a work in progress.


Standardized Training and References (Skills, Knowledge, Judgment)
Uncertainty on what to do in the first two years of the job was common. In 2001 we initiated a standardized training (on-the-job) program for nurses with 2 week, 1 month, 6 month and 2 year goals. Although logic predicts learning should come in the order of knowledge, skill, judgment we’ve found practically that skills, knowledge, judgment is easier to learn. The first month is focused on the basic skills, the next 6 on knowledge and the first 2 years on advanced skills and knowledge. We’ve now added standardized references to the package so nurses have less hunting to do for information. Items include written emergency procedures, common drug monographs, and written basic skills.

Tomorrow I’ll blog about emergency drills, standardized histories, standing orders and cross coverage by ancillary services.

Lean Thinking

Most of what I've been describing has to do with either lean thinking or six sigma. For a good reference on the topic I'd refer you to Lean Thinking at

http://leaninsider.productivitypress.com/



They seem to have some good references and books if you're inclined that way. I don't have any financial interest with them -- I just thought it was a good blog.



Ian.

Finding Waste

Imagine you’re clinic experience from the patient’s perspective. Better yet, come in one day after lunch, when the clinic is filling up and walk through the door. Sit down and watch what happens. There are all number of clinics and health care providers reading this around the world so experiences will differ.

Some will have just a few patients and a quick reception, others will stand in front of a glasses partition waiting to be acknowledged and others will be welcomed and brought right in. The desirable experience from the patient’s point of view is the latter but few clinics run this way unless they are underutilized.

Why don’t they run this way? Imagine a clinic where every step of the process ran at exactly the same speed. Check-in was 2 minutes, review of the medical history and vital signs was 5 minutes, time with clinician is 10 minutes and check-out was 2 minutes. There is zero variation to each step. Since the rate limiting step is the clinician at 10 minutes patients can be booked every 10 minutes and booked to arrive 7 minutes prior to their appointment with the clinician. Since patient 1 has check-out just prior to patient 3 check-in only one person is needed at each process (one administrator).

But life is rarely so pretty. Having different appointments take unplanned amounts of time is called variation. For instance a 10 minutes block of time may be 7 minutes or it could be 14 minutes (or 40!). This is what causes wait and waste to occur. In a service industry it is not the person having the appointment that experiences the waste – it is the people down-stream. For instance, the person that requires 15 minutes of time in a 10 minute appointment block has no waste; it is the next and subsequent people.

But waiting will happen whenever there is a bottle neck or a high degree of variation. Most people understand intuitively why a bottle causes a problem (e.g. the provider spends 30 minutes with everyone and all other steps are 2 minutes each) but they don't always notice why variation causes the issue.

So what can be done about it? The answer is found in looking at it from the patient’s perspective. Some clinics will put up a sign saying “one problem per visit”. From the patients perspective this is extremely wasteful (even though it may help the clinic run on time). The other solution is better screening to build a better schedule. If someone needs 30 minutes to go through their “problem list” they must be willing to wait longer to get in but get it all done at once (see the block booking blog).

I would ask that you take a look at your clinic and think of one sequence of events (or processes) that a patient goes through and write it down in sequential order. I am always looking for examples and suggestions so please post any to the comments page for everyone to review. Create an a simple flow map of the process that the patient goes through, either booking a procedure or follow-up or when they walk in the door.

Wasted Time

"Time waste differs from material waste in that there can be no salvage. The easiest of all wastes, and the hardest to correct, is this waste of time, because wasted time does not litter the floor like wasted material."

-- Henry Ford, Today and Tomorrow, 1926, p. 114

How many people reading this blog can already pick out 3 processes (maybe going on right now) in their clinic that are hopelessly inefficient? I’m assuming that most of us can answer yes to that question. Time waste is a difficult concept in healthcare because the end result (namely treating the patient) is still accomplished.

But the more people in the system, and the longer it takes them to get through it the more inefficient the clinic will be and the more people have to wait. The concept that any wasted time affects people ‘downriver’ is a tough one to accept. But it is very true. Another way to think about it is that “time saved with one patient can be spent with another”. But what is wasted time? Not all waiting is waste. For instance, waiting for local anesthetic to take effect, a wound to heal or antibiotics to act are all processes working not waiting. On the other hand, having someone sit in reception waiting for an open room, letting them wait for the provider while he/she sees another patient and waiting on hold on the phone are all waiting and waste.

Finally the greatest waiting waste is time in between appointments. Because time wasted needs to be judged by the yardstick of the patient time in between appointments is usually the greatest wait. Decreasing the time between appointments, improves the process for the patient, decreases the number of the people in the system which in turn improves efficiency and simplifies administration. For a discussion on which types of waiting is waste see the link below. Which process has the greatest waste in you’re clinic?

http://blogs.isixsigma.com/archive/is_a_wait_always_a_waste.html

Employee Suggestions

This week I had a bit of surprise. I was giving a tour of our clinic to someone that is making his own clinic green . As I checked our office to find out how green we really are I was told that one of the clinical assistants had been leading the charge to decrease waste in the labs. It suddently dawned on me that our office does not foster an atmosphere to encourage suggestions.



On of the major corporate goals of lean and six sigma is to use the brain power that you have in the business. After looking over other blogs I came across this interview of Owen Berkeley-Hill. In it he compares the number of suggestions per year per employee at Toyota to other companies. Apparently Toyota receives 24 suggestions per year per employee. In our practice with approximately 50 employess that should garner 1200 per year (right now we're not close to that).



For those of you in primary care I'd ask you -- when was the last time you had a formal suggestion from an employee? How many do you get a year? When did you encourage and implement a change based on an employee's suggestion? For the employee's reading this blog -- how many of you could put a suggestion foward and have it acted on in a serious manner?


For those in the dental community this is Dental Assistants week. If you forget how important DA's are to the profession take another read of the Exception Dental Practice Management blog

Technology, Change and Wait – Project Failures

I’ve recently seen two major IT projects fail due to “lack of user interest”. In both cases, the IT people had put in a lot of hard work and had advanced technology but were left disappointed and bitter. In one case, the project was for digital entry of drug orders in a hospital. It decreased ‘defect’ rates but made the process run less lean. In the other, it was a web-based system to re-order third party supplies after surgery. There were more errors due to data entry and it ran less lean. The failures were not due to a lack of initiative or ingenuity but a failure to improve the process flow.

Whenever our clinic has a suggestion from IT we first put the change into a flow map of the overall process. The process is constructed from the patients’ perspective. Changes that we make to the process have to improve the quality of care or time it takes. If the change doesn’t accomplish either goal – there is no point to doing it. If the change doesn’t achieve both goals it will have an uphill battle.

That being said, sometimes you have to look hard to see the improvement.

Let’s look at two changes and how they affected process flow:



A suggestion to go to completely digital charts. A process flow map (see diagram for an example) showed that because we often see patients in rapid succession (with the nurse seeing them too) the steps of log-in, log-out and typing rather than writing slowed the process. The decision was made to continue with paper but certain aspects would be digitized. When we can have tablets with stable wireless networks at a reasonable cost the change will come.



We are a referral based specialty clinic so the acceptance of patients was usually done by phone or fax. There is a digital system to manage referrals. When we added email referrals as an option the system broke down due to entry errors, misfiling, etc… What we thought would improve flow actually hindered it. The process was reexamined and the software provider for the main patient database was involved. For a small cost, code was written such that emails are automatically brought into the system and when they’re reviewed by our booking staff (to contact the patient) an email is automatically sent back with details.

Our clinic invests heavily in IT infrastructure but the point is to improve access and care, not to “be digital”. I think it would help to have the IT people bedside for several days before starting any project. Have them come in and work a busy night in emergency or a lonely night on the wards. The point is not to generate empathy, but to help them construct a process flow map of how an IT project is going to be used.

In any process, improvement can be achieved in two ways. Either decreasing the error rate (or defect rate in six sigma terms) so that work doesn’t have to be repeated or increase efficiency (or in Lean terms to lean it down and decrease the variation). My experience is that the defect rate is the most often cited reason for IT changes whereas Lean changes are easier to ‘sell’ to the healthcare workers and to improve and control. Perspective is everything. Every project, big or small, needs to have a process flow map constructed to determine whether it’s really going to help the people for which it’s being designed. But in a healthcare, the patient is the metric that really counts so when a project is suggested construct the map from the perspective of the patient. Remembering that we are here to benefit patients is not just a "corporate goal" but a valuable tool in implementing new projects.

Wait Time -- A Universal Yardstick?

How much health care is too much and how much is not enough. In the United States the cost is the problem whereas in Canada it's access to care. Are the two related?

The time from seeking care to treatment is a good indicator of the level of service. When the helath care wait time is low there can be an excess of resources and when it is high there are not enough (in a system that is full). In theory, health care wait times can be calculated (and even better predict them going foward) for each sector of the system and resources allocated appropriately. Currently many governments are calculating wait times in the emergency rooms, monitoring patient flow and time to surgery. But wait times can be manipulated. Surgeons can limit consultation time so the actual time on the wait list for surgery is low, emergency rooms can leave the patients with the ambulance crew prior to registration.

Instead, wait times need to be considered from the patient's perspective. Not only will it better reflect the actual wait involved but it might allow for more solutions. Imagine a patient that phones the doctors office. If the wait time for the front desk is only measured as the time on-hold with the office administrator we see only half the story and consequently half the solutions. In this instance, the only option is to either hang up or keep holding. If the wait time is measured from the time the decision to call is made other options such as email, fax, etc... also become apparent. Both email and fax would potentially decrease the wait time and relieve the burden on the administrative staff.

While patients may choose to accelerate or delay treatment and inadvertantly manipulte wait times, our data suggests that the mean wait is a good predictor of availability in the clinic. Most of the patient populations have well defined normal curves with predictable variations. Since representative survey populations are already common in politics; can the same solution not be extended to health care? We don't need to record every surgery and every wait time, just a representative sample. This would significantly simplify the burden on the information technology sector in health care (who is currently trying to connect many different clinics) and potentially provide accurate data over wider sectors. To determine how many patients need be surveyed and across which sectors, it would be simple enough to look at existing data for power and size calculations. From there a uniform, automated system could be implemented for all sorts of health problems not just those choosen as priority programs.

More and more institutions are rightfully focusing on wait times and so should smaller clinics. I think we'll find that as systems evolve a universal yardstick for health care delivery will not only let us see the problems, it will let us see the solutions.

The Biggest Bang for the Buck

What gives the best “bump” to efficiency in a clinic? If I could pick only one tool to decrease health care wait times what would it be?

Offices world wide have a broad spectrum of automation (computerization) and business practices. My old family doctor had his wife run the front desk, the waiting room had five chairs and there was one exam room. I rarely waited once I arrived at the office. On the other hand, I’ve seen emergency rooms with open beds, lots of staff, enough computerization to launch the space shuttle and still experienced 3-5 hour emergency waits.

I can think of many tools that should, in theory, improve the efficiency of a clinic and patient flow, thereby decreasing helath care wait times. There are certain tools that make processes work faster, such as computerized billing, email confirmation, digital lab results and the like. I consider tools like these “velocity tools”. They improve efficiency by leaning down the time of a process.

There are tools that make mistakes or errors on the part of the clinic less likely such as automatic recall schedules and fool-proof treatment tracking. In turn, less mistakes results in less repeated work or more time for clients. There are tools that allow better control of scheduling and patient flow such as computerized booking. These tools decrease the amount of variation in the system by allowing for control of booking and the creation of “pull” which improves efficiency.

Having been analyzing our own data for 7 years I believe that the tools that make mistakes less likely have the biggest benefit. In an already busy practice, velocity tools and variation tools can change individual processes greatly, but the overall effect is only 5-10% each. On the other hand, decreasing errors seems to change the burden 10-20% across the board.

In our case, it means digital treatment plans and recall schedules with strict algorithms to prevent errors. The system makes it impossible to forget about follow-up work to be conducted. Imagine a patient that comes in for a problem then neglects to follow-up. There is time spent in the office tracking down why the person hasn’t followed up and then repeating the work if too much time has elapsed. Not only do appointments and clinic work need to be repeated but so does the administrative burden. In healthcare, this lack of follow-up includes a significant number of people.

Looking back at the data, that single step of fool-proof treatment tracking changed our efficiency by 10-20%. I don’t think I can find another single tool with as large of an effect over the entire practice. So, the one tool I’d pick before all others is a computer system that tracks treatment and follow-up.

Talk about Wait Time and Delayed Care in Clinics

Welcome to the wait time and delayed care blog. This blog is about the techniques and tools of managing wait times in a professional setting. Doctors’ offices, lawyers, dentists, chiropractors, other health care professionals (as well as hairdressers) all run into the same problems because of quick appointments with a large number of people. My premise is that if the staff that manage scheduling and patient flow can make modest improvements, major changes can happen. Most of us can find ways of shortening a 20 minute appointment by 4 minutes. This is a 20% improvement. But if that same 20% improvements are achieved with the family doctors across Canada; that's an extra 3,400 (20% of 17,000) physicians worth of time.

If you are the person that is organizing or managing an office, business or clinic then this blog is intended for you. Our office works hard to run on time and get people in quickly, despite being in an under serviced area. Shortening wait times is not just a matter of increasing the number of people/providers that care for the patients it's a matter of better management.

There are four main concepts.
1. Time saved with one patient can be spent with another
2. Work that runs smoothly will run faster
2. Having to repeat work wastes time
3. To improve something; you have to be able to measure it.

Industry (e.g. Toyota, GE, etc...) long ago embraced these concepts through Lean, Six Sigma, DMAIC and other programs. But many businesses still don't use them to improve the bottom line. In the service sector we need to be even more diligent because wasted time affects our patients.

I hope you'll find the blogs helpful and I look forward to bouncing ideas off of anyone interested in the topic. Health care wait times, delayed care, waiting lists, block booking, priority booking, queuing theory, six sigma, lean, repeated work, critical time to treatment and many other topics are all up for discussion. My hope is many people will make small changes that can have a major impact.