Tuesday, July 30, 2013

Boyd's Megarant Concerning Healthcare Reform Part 3 - LEAN

Toyota: Reputation for building high quality, long lasting, inexpensive automobiles.
Cadillac: Reputation for building high quality, long lasting expensive automobiles.

Two car makers, two very different philosophies on how to build a car.

Toyota is widely considered as the originator of the LEAN manufacturing process. Though upstart car makers like Saturn adopted the same principles before GM (the maker of Cadillac) bought them out and ruined them. The Toyota model looks like this.

One car built at a time. Every line worker has the power to stop the assembly line if they see something wrong or something doesn't meet a certain specification for quality. One car is built. When it rolls off the line it goes through one more quality assurance check and then is ready for shipment. This is called, in the vernacular, Single Piece Flow. Do one thing at a time, one product at a time, excellently every time.

What ruined Saturn? GM ruined Saturn and it basically boils down to their American philosophy of manufacturing. Every Cadillac built that leaves the assembly line goes to one of two staging areas; Minor Problems or Major Problems. In these staging areas, defects in the manufactured automobiles is corrected by a team of troubleshooters prior to being delivered to the dealer showrooms. This is called, in the vernacular, Batch Flow.

The result? Two high quality cars, one more expensive, not just because of the name on the badge, but because of the process taken to create them. One, Toyota, very efficient. The other, Cadillac, quite inefficient.

And now for health care... there are two very different kinds of hospitals out there - not to over simplify the problem, but every hospital can be categorized into one of these two manufacturing processes. Single Piece Flow (LEAN) or Batch Flow (the anti-LEAN). There are many at various odd stages between the two but really, our hospitals are efficient or not. If you've worked in or been the victim (benefactor?) of a hospital you probably have a pretty good idea of what I mean.

The Toyota model of LEAN manufacturing has been introduced into our health care industry in the United States. It started in the laboratories. I will now describe the processes in the Laboratory of two very different hospitals - the LEAN and the anti-LEAN.

Hospital A - Blood is drawn from a patient in their room by a Phlebotomist. The test tube is placed in a rack the technician carries around from room to room, floor to floor, until the rack is full and it is turned into the Lab for processing. The lab takes this rack of test tubes and collects them until the gather enough together to place into their mega standalone chemistry analyzers. This entire collection of test tubes filled with blood are all analyzed simultaneously ( or nearly so) and the results are all logged at once. The results are then delivered back to the units from which the blood was drawn and the logged in the medical record - generally manually and all at once. This is BATCH flow. The draw back? The first patient to have their blood drawn has had to wait an hour for their results. The last patient to give blood has waited, perhaps, 30 minutes or less. The Lab shows a turn around time of 10 minutes because it took 10 minutes to run the racks of collected blood. This "lost time" phenomenon is a hallmark of all BATCHING systems. If the analyzer breaks, ALL samples are delayed or lost.

Hospital B - Blood is drawn from a patient in their room by a Phlebotomist. This sample is delivered to the Laboratory within minutes of it being drawn. The barcoded tube is placed in the analyzer immediately and within minutes the results are returned to the doctor electronically and the medical record is updated automatically. The true turn around time for this blood sample is 15 minutes or less. The phlebotomist, meanwhile, has drawn blood from the next patient, the sample sent, analyzed, and results returned in minutes. The result? Every patient has the same quick turnaround experience.  If the analyzer breaks, only ONE sample is delayed or lost while the Lab reverts to their backup process.

This gives you the background for understanding how the LEAN manufacturing process is being introduced, at a cost of several hundred thousands of dollars per year paid to vendors or consultants who offer the analysis, LEAN training, and then get the heck out of dodge. Then it is up to the hospital to spend many more thousands on new Single Piece Flow analyzers, software and computers to crunch data, space renovations, and in some cases the addition of staff to monitor LEAN Processes going forward.

LEAN Basics- All LEAN programs can be boiled down to these basic tenets.

1) Eliminate Waste
2) Standardize Work
3) Single Piece Flow
4) Process Monitoring
5) On the Fly Corrections

1) Eliminate Waste - This is as simple as it sounds and yet much harder than one may suppose. This really means not having more supplies, tools, parts, etc. on hand than you need for a specified period of time. It also means the death of the souls of your packrats who save everything "in case I need it some day." The key to this tenet of LEAN is that one can not be concerned about "someday"; one is only concerned with now. Someday is taken care of in the next section.

2) Standard Work - this simply means that no matter who is doing the work, the work is always done the same way; tools are always where they are supposed to be; supplies are always stocked; supply reorders are always done at the same regular intervals; documentation is always kept uniformly. This way whomever is completing the task knows where things are, when to reorder supplies, and how to do the job.

3) Single Piece Flow - this is vital to LEAN processes. Take care of one thing at a time. In spite of our culture's insistence - or ability - to multitask, taking care of one customer at a time makes the customer feel special and allows the server to concentrate on just them. Taking one test tube at a time, within reason, makes turnaround time consistent for all customers. Repairing one machine at a time, does the same thing for a customer waiting for their machine and allows the technician to focus on this one thing, increasing thoroughness and efficiency, clear work spaces, all tools readily available; no searching through tool kits to find the ones needed for multiple jobs, etc.

4) Process Monitoring- during LEAN assessment, consultants will stage video cameras around the area being assessed, allow a few days for staff to forget the cameras are rolling, and then record a normal business day. From this comes the concept of "Move the Damn Box". During at least one video session it was noticed that staff were like ants in a disturbed anthill, walking all over the place, sometimes miles of cumulative distance in the period of a day. Sometimes these miles are logged inside one room. It is all done in short bursts of frenzied activity. During one of these sessions an equipment operator kept tripping over a box that had been "stored" in a walkway on the floor. When the video was reviewed, the consultant apologized, in advance, to the operator and then asked, "Why don't you just move the damn box!?!" Monitoring the process to make sure it is as efficient as it was first created eliminates what is called "behavior creep" - lapsing back into lazy, sometimes dangerous behaviors over time.  If something isn't working making adjustments.

5) On the Fly Corrections - comes out of constantly monitoring the processes  and being flexible enough to make common sense adjustments to keep things efficiently running. This is kind of like performing a daily (hourly?) tune up of one's car.

The modern health care institution has become so layered with bureaucracy, inefficient process layers designed to correct inefficiencies in other layers, that LEAN is no longer a concept, though EVERYONE I've ever trained in these concepts ALWAYS says something like "that's just common sense! I naturally think like this. Why are you wasting my time training me on something that's just common sense?". Unfortunately they say these things as they are returning to their desk, piled high with stacks of papers and folders, to work on 3 different devices disassembled on their workstations. It sounds simple. It is. But training healthcare workers in these simple principles costs health care facilities hundreds of thousands of dollars per year.

LEAN is good. LEAN should be implemented in health care - all departments from housekeeping, clinical engineering, facilities maintenance, nursing, administration, dental clinics to ICUS and Open Heart rooms. Any attempt at health care reform that does not mandate efficiencies, like LEAN, to be implemented is putting a bandaid on a sucking chest wound.

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