blainereichart.weebly.com€¦ · Web viewThe Kaizen approach at LHC was used to implement Lean when focusing on the work systems or process that need to be improved. (AHRQ) (AHRQ)

Running Head: IMPROVING CARE DELIVERY

Health Communications Program Analysis: Final Paper

Steven Scheelk, Kylie Riffey, Blaine Reichart & Mathew Heady

University of Saint Mary

715 Communications & Relationship Building

October 17, 2015

Improving Care Delivery 2

Abstract

Lean is a system implemented into health care organizations to improve efficiencies and patient

experience. There are different goals that every group within health care organizations use Lean

to help improve their efficiencies and patient experiences. There are five points that are focused

on when implementing the Lean system into organizations. Excellent service, best people,

clinical quality and safety, resource stewardship, a caring culture, and at the center, outstanding

patient satisfaction, are the five points that Lean focuses on (AHRQ, 2014).


Lean Goals

“The initiatives' goals and accomplishments include transforming the culture to one that

promotes trust and openness to encourage conversations about performance and removes

bureaucratic barriers for employees and physicians in order to create an outstanding patient

experience (AHRQ, 2014).” The work that is done in health care facilities is focused around the

care of patients. Lean brings in all aspects that work to improve the experience that patients

have. Service is not what is remembered by patients but the experience they had is what they

talk about when it’s all said and done. Lean brings the best performance out of organizations to

promote the best experiences around.

Goals for Lean are brought about by the providers that drive the processes. “Interviewees

mentioned at least one of the following goals for Lean: improve efficiency and reduce process

time, improve patient experience, integrate process improvement into the culture, and increase

clinician time at the bedside (AHRQ, 2014).” Goals are discussed by interviewees based on the

projects that they participated in for Lean.

The overall goals of Lean are to improve efficiency, reduce process time, and eliminate

waste. These goals bring the best out of health care organizations to provide the highest rated

experience for the patient. Improved efficiencies included organized spaces, reduced travel time,

patient and staff flow, and reduced cycle times (AHRQ, 2014). Improving on these areas has a

direct reflection on the experience that patients have in the Lean centered health care facilities.

“The initiatives' goals and accomplishments include transforming the culture to one that

promotes trust and openness to encourage conversations about performance and removes

bureaucratic barriers for employees and physicians in order to create an outstanding patient


experience (AHRQ, 2014).” The work that is done in health care facilities is focused around the

care of patients. Lean brings in all aspects that work to improve the experience that patients

have. Service is not what is remembered by patients but the experience they had is what they

talk about when it’s all said and done. Lean brings the best performance out of organizations to

promote the best experiences around.

Goals for Lean are brought about by the providers that drive the processes. “Interviewees

mentioned at least one of the following goals for Lean: improve efficiency and reduce process

time, improve patient experience, integrate process improvement into the culture, and increase

clinician time at the bedside (AHRQ, 2014).” Goals are discussed by interviewees based on the

projects that they participated in for Lean.

The overall goals of Lean are to improve efficiency, reduce process time, and eliminate

waste. These goals bring the best out of health care organizations to provide the highest rated

experience for the patient. Improved efficiencies included organized spaces, reduced travel time,

patient and staff flow, and reduced cycle times (AHRQ, 2014). Improving on these areas has a

direct reflection on the experience that patients have in the Lean centered health care facilities.

Target Audience

Lean focuses on the elimination of waste within a facility; this is any activity that

consumes resources such as, staff, time, money, and space. It also does not add any value to

those being served by the process (AHRQ, 2014). For this project a target audience needed to be

determined. This would be geared toward health care organizations. The Lean project focused

on finding hospitals willing to participate in their case study. The Agency for Healthcare

Research and Quality (AHRQ) and the American Institutes for Research (AIR) conducted five


case studies. For one of the facilities to be chosen for a case study they needed to have

implemented the Lean project in two or more of their projects. This would have included

projects such as rapid cycle improvements or rapid improvement events (AHRQ, 2014). The

health care organizations that were chosen for the study were a critical access hospital, an

academic medical center, a public safety net hospital, a tertiary care hospital, and an organized

delivery system (AHRQ, 2014). Out of these health care organizations chosen for this project, it

was broken down into smaller units consisting of two inpatient units, one cardiology unit, three

outpatient clinics, two emergency departments, two system-wide, and three surgery units

(AHRQ, 2014).

Thirteen distinct projects were chosen for study within the five case study organizations

(AHRQ, 2014). Nine of the projects selected were studied from a prospective analytic

perspective, and data was collected at the beginning of the project and during the course of the

project. The other four projects were studied from a retrospective analytic perspective, and the

data was collected after the project concluded (AHRQ, 2014). Ten of the projects focused on

Lean implementation for just one department or operating unit within the health care

organization. The other three projects focused on the entire hospital's operations, including the

construction of an entire hospital using Lean principles (AHRQ, 2014).

The Lean project can be used within any organization that wants to eliminate waste

within their organization. The Institute of Medicine reports that 30 percent of the U.S. health

care spending which is about $750 billion a year was wasted in 2009 on unnecessary services,

excessive administrative costs, fraud and other problems (Shalby & Rolfes, 2012).

Patients can be used as a target audience to give organizations ideas of where to cut waste

such as multiple lab tests. It was reported by a patient that since he is diabetic he has two


different doctors he sees, a primary physician and an endocrinologist. This individual suggested

ways to cut cost of health care would to be to have physicians coordinate their lab work so he

only needs to have lab drawn for all the tests needed for both physicians instead of coming back

two different times for each physicians labs to be drawn (Shalby & Rolfes, 2012).

With medical records hospitals have helped to eliminate some of this waste because the

physicians within the facility can access the patient’s entire medical record and are able to see

what other physicians have ordered and their progress notes and consultations. The Lean project

can be applied to any facility that is looking to eliminate waste and increase patient satisfaction.

Lean can be applied to the overall facility such as how the facility orders and keeps track of

supplies so not to over order or waste too many supplies within each unit. Lean could also be

applied and studied within individual units such as decreasing wait times within an emergency

department by providing “fast areas” that have a physician that sees all patients that are “green”

status. These are the patients that are just needing medication refills, abrasions treated, or other

minor treatments.

Materials Developed

In 2000, the organization began working with the consulting firm on process

improvement through Six Sigma projects. The consulting firm, having developed deep expertise

in process improvement based on work to improve manufacturing processes, began offering

consulting services in process improvement, particularly Six Sigma (AHRQ). By using the

consulting firm LHC was able to determine gains which were contributed to the use of Six

Sigma. Based on those initial results, the organization continued to adopt additional process

improvement methods from the consulting firm's Toolbox for quality improvement, including

Workout, Change Acceleration Process (CAP), and Lean (AHRQ).


LHC introduced staff to the Lean principles and other process improvement tools.

Training at LHC is conducted by internal staff in the Management Engineering Department.

Training on Lean principles and initiation of Lean projects is fully intertwined. The Kaizen

approach at LHC was used to implement Lean when focusing on the work systems or process

that need to be improved. (AHRQ)

Although it was not linked to Lean, the new electronic health record (EHR) was

introduced to staff in the outpatient physicians' offices through group trainings. Some physicians

were given one-on-one training. One physician executive explained that until staff actually

begins using the new technology or process, they might not be able to identify all of the

problems or concerns and instead might "learn as you go." However, this was not the case for the

Lean projects that were implemented and studied as part of this research, since the processes

were tested in advance of wider dissemination and rollout. (AHRQ)

To improve the communication and speed of inpatient transfer in and out of acute care

bed units, the hospitals turned to the patient room closed circuit television system, the

GetWellNetwork (GWN). The GWN includes a utility for use by the housekeeping department,

called "Click to Clean (CTC)." When a patient is about to be discharged, a unit nurse clicks the

option which informs environmental services that they will soon need to clean the room. The

nurse strips the bed and ensures that the patient has all of his/her belongings and does not leave

anything behind. At Hospital 3, transport staff were responsible for discharging patients or

escorting them out of the hospital, but during peak times, they could not meet the needs in the

ED and the inpatient floors. To improve the time it takes to discharge patients, Hospital 3 shifted

the responsibility for discharging patients back to the unit staff. Once the patient is ready to

leave, the nurse clicks another option to tell the environmental services staff that the room is


ready to be cleaned. When the room is cleaned and ready for a new patient, an environmental

services staff member clicks the option that shows that the room is available for a new patient.

Then the nurses can assign the bed and call the ER or operating room (OR) to let staff know the

bed is available (AHRQ).

The "Click to Clean" system was working effectively immediately after the Kaizen event,

but staff wanted more information about what to expect. So the project team developed a new

tool: a morning and afternoon "state of the house" that showed the current census in the ED, OR,

and on each of the floors. Staff used this information to help prioritize their work, pointing

physicians to where they should focus their time, which was to discharge patients from the

inpatient units so that the beds could be opened up for those patients who were waiting for

inpatient admission. (AHRQ)

The Surgeons' Preference Card project was part of a larger process transformation of the

operating rooms' information systems. Surgeons' Preference Cards are used to draw equipment

and supplies before surgery, check for lost objects before closing out surgery, and charge after

surgery. At each hospital, there were between 1,200 and 2,800 preference cards, each with an

average of 40 items. The goal of this project was to update the surgeons' preference cards and

define a standard process for managing surgeons' preference cards through their life cycle. The

project focused on the surgical department’s at all four hospitals and was also intended to

facilitate better communication between the hospitals and the surgical practices that schedule

surgeries and conduct follow-up appointments with patients. (AHRQ)


Test Marketing

Lean is a system that was tested in different health care facilities within specific areas

that focused on the experience that the patient has. Test marketing was done by implementing

Cross-Cutting Projects, Outpatient Medical Records and Patient Flow, Outpatient Electronic

Health Records, and Surgeons’ Preference Cards.

“Corporate executives reported that Lean was initiated in 2003 and, according to a few

hospital executives and managers, did not ramp up significantly until 2006–2007 when a large

educational program was launched to inform staff about Lean. In 2006, LHC and the consulting

firm cosponsored a week-long International Lean Healthcare Seminar. During that week, five

projects were implemented with health care professionals from 18 hospitals and health systems

and four countries in conjunction with LHC and other process improvement leaders (AHRQ,

2014).” Test marketing that was done required more effort on the educational side of Lean to

get the importance of it flowing throughout the test facilities. When health care providers

attended the Lean seminar they were then aware of the impact that Lean can have on the

experience their patients have and take away from their facility.

Test marketing is very important for Lean to be implemented because it is hard to show

examples of how a patient’s experience can be improved by focusing on eliminating waste and

other goals that Lean stand prideful for. When the staff members learned about Lean they were

willing to try implementing their practices into the system they know best for patient care. The

test markets have shown to improve patient experience and overall functionality of the health

care facility.


Evaluation of Success

The success of implementing Lean as an organizational redesign approach was measured

by a collection of qualitative data. Five diverse health care organizations were selected and

considered to be the “cases” for the study. The organization must have applied Lean in two or

more projects in order to qualify as a case. The health care organizations selected included a

critical access hospital, academic medical center, public safety net hospital, tertiary care hospital,

and an organized delivery system (AHRQ, 2014). Projects from each organization were selected

for evaluation. The organization was allowed to define “projects” but usually it referred to

specific Lean events in a department, unit, or segment of the value stream (AHRQ, 2014). The

focus on specific projects allowed for better understanding on how Lean works at each

organization and how Lean success may be affected by variations. This information allowed for

a detailed analysis to examine how factors influenced Lean implementation, sustainability, and

success.

A total of thirteen projects were studied from the five case study organizations. Nine

projects were studied from a prospective analytic perspective with data being collected at the

beginning and during the project. The remaining four projects were studied from a retrospective

analytic perspective with data being collected after the conclusion of the project. Ten of the

projects focused on Lean implementation within a single department while the other three

projects used a more broad approach by focusing on the entire hospital’s operations (AHRQ,

2014).

In-person interviews, digital diaries, collection of documentation, and telephone

interviews were all used in the collection of data. Methods of data collection varied by analytic

perspective and the stage of implementation of the Lean project (AHRQ, 2014). Data was


collected during pre- and post-implementation with in-person interviews and collection of

documentation. The purpose of these interviews was to determine the organizational culture

adjoining Lean, assess the organizations’ interpretation of Lean and quality improvement, gain a

better understanding of the implementation strategies used by each organization, and to gather

data about the local environment, structures, and processes that were specific to the application

of Lean (AHRQ, 2014).

A qualitative data analysis software program called NVivo was used to manage and

analyze all qualitative data collected, which included in-person interviews, telephone interviews,

and digital diaries. NVivo was designed to accommodate many diverse types of qualitative data

and data was transcribed before it was uploaded to NVivo. Documents in print were scanned into

the system. A coding system was developed based on the conceptual framework in exhibit 1 for

interviews and digital diaries and an inter-coder reliability was tested after every twenty

interviews. The average reliability for all coding was leveled out at 92.8 percent. Data was

analyzed for each individual case and qualitative techniques were used to draw conclusion from

the data collected. These techniques included noting patterns/themes, plausibility, relationships

between variables, and finding intervening variables. Data that was provided by organizations

were summarized using descriptive statistics and added to the cases as needed.

Data using qualitative research is most commonly collected using open-ended, emerging

data that is then developed into themes (Campbell, 2014). Using qualitative data allows for an

exploratory study and often indicates that the participants or topic of the study is limited with

little current research done. Characteristics of qualitative research include the research taking

place in the natural setting, using multiple interactive methods, providing emerging data rather


than prefigured, and being profoundly interpretive (Campbell, 2014). The study of Lean

respectfully represents the collection and interpretation of qualitative data.

After much interpretation of the collected data, positive outcomes were identified as a

result of implementing Lean within healthcare facilities. The procedure card project was

considered successful because it reduced the number of cards and nurses were satisfied since

they did not need to leave the surgical room as frequently to retrieve supplies and equipment.

Physicians are also satisfied with the fact that they have appropriate supplies and equipment in

the room when needed. Additional outcomes attributed to Lean include:

A decrease of procedure cards by 57 percent.

Heightened and continued engagement of staff.

Overall increase in physician satisfaction.

Reduction of paper printed which aided the specific budget and allowed for

more accurate procedure cards.

The current study has two potential sources of bias that present limitations. First, the

responses to questions are associated with the language and sequence of the question and as a

result conclusions might also vary. Second, responses require interpretation by analysists and

different analysists interpretations may differ from one another’s. Although these limitations are

present, the reliability of the coding, as previously discussed, suggests that these are not serious

sources of bias.


Conclusion

The implementation of Lean within the health care industry will help to improve

efficiencies and patient experience. The five main points of lean that are focused on when

implementing lean are excellent service, best people, clinical quality and safety, resource

stewardship, a caring culture, and outstanding patient satisfaction. These five points are the key

factors at which Lean focuses on which is the basis for improving efficiencies and patient

experience.


Exhibit 1. Conceptual Framework. November 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/system/systemdesign/leancasestudies/lean-exhibit1.html


References

Agency for Healthcare Research and Quality. (2014). Improving care through lean:

Implementation case studies. Retrieved from

http://www.ahrq.gov/professionals/systems/system/systemdesign/leancasestudies/lean-

intro.html#Definition

Campbell, S. (2014). What is qualitative research?. Clinical Laboratory Science: Journal Of The

American Society For Medical Technology, 27(1), 3.

BIBLIOGRAPHY Institute for Healthcare Improvement. (2015). Institute for Healthcare Improvement.

Retrieved from The Patient Experience: Improving Safety, Efficiency, and HCAHPS Through

Patient-Centered Care: http://www.ihi.org/education/InPersonTraining/thepatientexperience/

Pages/default.aspx

Shalby, C. & Rolfes, E. (2012). Waste in U.S. health care: Your first-hand accounts. Retrieved

from http://www.pbs.org/newshour/rundown/waste-in-us-health-care-your-first-hand-

accounts/

http://www.pbs.org/newshour/rundown/waste-in-us-health-care-your-first-hand-accounts/

http://www.pbs.org/newshour/rundown/waste-in-us-health-care-your-first-hand-accounts/