Process Redesign for Health Care Using Lean Thinking

A Guide for Improving Patient Flow and the Quality and Safety of Care

David I. Ben-Tovim

• Publisher: Productivity Press
• Year: 2017
• ISBN:
  9781315303932
• Edition: 1
• Topic: Business
• Subtopic: Industria dei servizi
• Index: Business

Process Redesign for Health Care Using Lean Thinking is a response to a simple, but hard to answer, question and is the result of the experiences of a working doctor who was also the chief safety and quality officer of an Australian teaching hospital. At this hospital, he observed that the Emergency Department was staff by talented, well-trained, and respected doctors and nurses. The facilities were modern, and the work load unexceptional, but the department was close to melt down. Bad things were happening to patients, everyone was blaming each other, lots of things had been tried but nothing was getting better and no one could explain why. The problem was not a lack of technical knowledge or expertise, the problem was that no one stood back and said, "what's the best way to move 200 or 300 patients a day through the complicated and varying, sequence of steps needed to sort out the many different problems that bring patients to our department?"

These challenges are faced by hospitals and health services all over the world. There are difficulties with patient flow, congestion, queues, inefficient utilization of resources, problems engaging clinical staff in improvement programs, adverse incidents, and budget constraints.

Lean thinking and value stream analysis gives hospitals and health services struggling with these issues the insights they need to help themselves. This book provides a method that systematically turns those insights into working programs of service and system redesign.

The book is divided into two sections. The first section gives the background to the approach, and systematically works through the Process Redesign methodology, step-by-step. The second section is a series of case studies that show the methodology in action, what worked and what didn't work. The goal of any process redesign is simple: the right care, for the right person, at the right time, in the right place, and right the first time. This book helps the people who work in hospitals and health services realize these goals by working together.

Chapter 1

Introduction: An Accidental Redesigner

I am an accidental redesigner. Yet, I have spent more than 10 years attempting to redesign the way care is organized and delivered in hospitals and health services.

I am a psychiatrist and clinical epidemiologist by background. The Flinders Medical Centre is a 500-bed teaching general hospital in Adelaide, South Australia. In 2000, I became its Director of Clinical Governance. My job was to oversee safety and quality systems throughout the hospital.

The main problem was apparent. The Emergency Department had become catastrophically congested. Patients were being managed in far-from-optimal settings, and problems that started in the Emergency Department were showing up all over the hospital.

The hospital was not facing an excess patient load, just the work the community had every right to expect the hospital to be able to manage. A variety of efforts had been made to improve things. None had provided lasting relief. Then, my colleague Melissa Lewis came across something called Process Mapping on the Internet. It seemed to involve bringing together the people who worked in a unit and asking them what they did to move the patients through the unit. We thought Process Mapping might help us understand what was going on. Although the senior staff members who worked in the Emergency Department were confident that they had a pretty good handle on how the department worked, they were willing to try anything to get the department working, including Process Mapping.

Process Mapping

One Tuesday morning, about 20 staff from the Emergency Department, Melissa Lewis, and I gathered in the Emergency Department seminar room. Every discipline group working in the department was represented, from the Patient Service Assistants who did the cleaning, fetching, and carrying, to the most senior Emergency Physicians.

Melissa and I decided to ask the participants to describe what they did, step by step, from the moment a patient arrived at the glass doors at the entrance to the department until that patient left the department and went home or was admitted to an in-patient unit.

Over three long sessions, we mapped out the sequences of care the department provided. It was a revelation. As soon as we started, it became clear just how confusing the care processes had become. The Emergency Department staff were as surprised by this as we were.

Every patient who comes to a major Emergency Department in Australia sees a specialized Triage nurse. The Triage nurse is stationed, literally and metaphorically, at the front door. She or he makes a very brief clinical assessment of all the patients and allocates a Triage score to each one. A Triage score is the Triage nurse’s assessment of how urgently the rest of the staff in the department need to begin the work of providing definitive care: immediately, within 10 minutes, within 30 minutes, within 60 minutes, or within 2 hours. Many of the problems in the Emergency Department seemed to begin with the way Triage scores were being used. The Triage scores not only described patients but were also used to place patients in queues. Whilst this might seem to make sense, the case study in Chapter 20 makes it clear why this had become a problem.

As we presented our observations to various groups around the hospital, there was widespread agreement that something needed to be done—but what?

The Modernization Agency

A small group of us, including Jane Bassham, at that time the senior nurse in the Emergency Department, and Dr. Di King, the head of the Emergency Department, were able to spend a few days in London as guests of an NHS organization, the Modernization Agency (since then disbanded). We visited Emergency Departments in busy hospitals that had been transformed from war zones into acceptable places for staff and patients alike. Our Modernization Agency hosts, who were very involved in supporting the improvements, gave us copies of the book, Lean Thinking (Womack and Jones 2003), telling us that they had found it very useful. They gave us the book on a rather secretive, need-to-know kind of basis. The secrecy surprised us.

Later on, we discovered that there was a concern that if the Modernization Agency talked about learning from industry, it would be taken to mean that the NHS was going to be sold off to private enterprise, which was not the impression the government of the day wanted to make.

Back in Australia, we were also able to spend a few days with Ben Gowland, then a senior staff member of the Modernization Agency. Ben had played an important role in the changes we observed. We kept asking him what we should do. He told us that we were clever people, and we would be able to work things out for ourselves. While this did not feel very supportive, he was right. Under the inspirational leadership of Dr. Di King, we used our experiences in London and our reading of Lean Thinking to introduce some dramatic changes in the internal organization of the Emergency Department (King et al. 2006). Overnight, those changes improved our capacity to provide good, timely care. And over the next year, a hospital-wide dramatic decrease in the number of patients seeking redress for serious failures in the safety and quality of care implied that something was having an impact throughout the hospital.

Clearly, there was something to this Lean Thinking business (Ben-Tovim et al. 2007), even though at that time it was not being used in other Australian hospitals and health services.

Ben also said that if we wanted to make a lasting difference, we needed to create a team, with a formal structure and explicit governance, dedicated to improvement work. He said it was as important to think about the team as it was to think about the changes we intended to make. This was very good advice, without which we would not have given much thought to creating a team and a governance structure. The hospital management listened to Ben and set up a small team to “do Lean.” I was appointed its Director. Two full time, and one part-time, nurses and a psychologist completed the team. We established both the team (which included Melissa Lewis, Jane Bassham, Denise Bennett, Margaret Martin part time, and later Jackie Sincock and Lauri O’Brien) and a governance structure that brought together the senior hospital leaders. We decided on a name—Redesigning Care—and got started.

Why Redesign?

Why redesign, not design or improve? It is because the hospital already existed, with skillful and committed people already doing their best. We were not beginning with a clean slate. On the contrary, we were trying to improve care processes already in place in an institution that did not have the luxury of closing down until it got things sorted out.

Learning about Lean

Clearly, we needed to learn more about this Lean stuff. The team, plus some senior managers, went on a local university course in Lean Manufacturing. Our fellow students came from a variety of local industries. We learned as much from them as from the formal content of the course. Yes, the contexts differed, but we were all grappling with the same kinds of problems.

Most importantly, during, and after the course, as we set about trying to redesign care across the hospital, the team kept working together to try and make sense of what we were actually doing.

Then and later we were strongly supported by Julia Davidson, Michael Szwarcbord, and Susan O’Neill in various management roles. Paul Hakendorf, Chris Horwood, and John Gray were patient with us and helped us with the key tasks of data retrieval and analysis, as well as provided general and, much needed, support.

Invaluable contributions to both theory and practice have been made by the hundreds of clinical and nonclinical staff with whom we have worked, both at Flinders and across the country, and by the people who worked part time in the Redesigning Care team for longer or shorter periods.

So many people have been important that it is almost invidious to mention specific individuals or groups. But Peter Walsh from Lean Enterprise Australia has been a particular friend and support, as has the Lean community as a whole. Despite their many other responsibilities, Katherine McGrath and Tony O’Connell have provided invaluable support and encouragement. The list could go on but has to include the ever-patient Di Mackintosh and Kylie Thomas whose support and assistance have been crucial.

The Process Redesign for Health Care using Lean Thinking method draws extensively, though not exclusively, on Lean Thinking theory and practice. I begin with a discussion of the origins of Lean Thinking and some of the issues involved in adapting it for Health Care. I then move on to describe Process Redesign methodology in some detail. Brief case material is used to illustrate the principles and the evolution of that methodology. There are then four extended case histories in which I try to provide a more detailed picture of how Process Redesign for Health Care using Lean Thinking (frequently abbreviated to Process Redesign or Process Redesign for Healthcare) works in practice. Almost invariably, the most creative work was done by the staff on the ground. They know the work and, without exception, have been anxious to improve the quality of care they provide. The case studies are not intended to be templates for how to solve certain problems. They cannot be; Health Care problems need solutions that are relevant and specific to their context. The purpose of the case studies is to illustrate the Redesign Process and give a sense of how Redesign actually occurs. To make that possible, the extended case studies are based on the materials produced at the time.

Health Care involves people at their most vulnerable and private moments. To minimize the risk of identifying individuals, details that might identify specific participants, or institutional issues of any sensitivity, have been altered or removed, and if diagrams or figures are presented that are based on materials produced during Redesign programs, they have been altered and redrawn so that anonymity is preserved. Facts or figures that might identify individuals or specific services have also been altered to minimize the risk of inappropriate identifications. However, every effort has been made to faithfully describe the spirit of the Process Redesign programs and not make false claims for program outcomes. However, the case studies have been written up in a format that clearly separates out various phases of the work involved. That was how the work progressed, and where major deviations in the progression of work occurred, they have been discussed; however, case studies are by their nature somewhat simplified representations of a messier reality.

Writing up the case histories has only been possible because of the extensive documentation of the work as it progressed. It is a tribute to the efforts Denise Bennett and the other team members put into reporting to governance groups at each step on the way. Denise was a particular force for good in this area, and much of the credit for the consistency of the documentation must go to her leadership.

Throughout the text, when a personal contribution by a team member has been particularly clear, I have tried to identify that person’s contribution to the development of theory or practice, but again, whilst maintaining confidentiality and recognizing the importance of the team as a whole.

A Decade Later

A decade after this work began, there is a growing community of Health Care redesigners using Lean Thinking to redesign and improve Health Care processes, both in Australia and the rest of the world. I am delighted with the role I and my colleagues have been able to play in this development, and with the way the Australasian Lean Health Care Network, which the Flinders group has been part of from the start, has supported that development in Australasia.

Process Redesign for Health Care is for anyone who is trying to improve how their hospital or health service delivers care. I hope there is something in it both for the novice redesigner and the more experienced practitioner curious to learn more. Redesign is never easy. It is hard work. Things never go quite to plan. But it can be done. Process Redesign is a team effort. When faced with the common experience of not quite knowing what you are doing or what to do next, as the Flinders team always said, “have confidence in the method, and don’t miss a step.”

I

CONTEXT AND METHOD

Chapter 2

Craft, Flow, Mass

The term Lean Thinking first appeared in the book The Machine that Changed the World (Womack et al. 1990). The book was a summary of a global research program into car-making around the world. Lean Thinking was the term the authors used to sum up the distinctive production and managerial methods they observed at the Toyota Motor Company.

To understand what excited Womack et al., it’s essential to know something about the evolution of methods for making large, complicated objects, such as boats or cars. It is possible to look back in history to fourteenth century Venetian shipyard production or even earlier to the production of terracotta warriors for the tomb of the first Emperor of Qin who died in 221 BCE, but the important period to concentrate on is the end of the nineteenth century. That was when what was commonly described as the British method of manufacturing gave way to the American method, out of which emerged mass production as we know it today.

This short history (Lazonick 1981; Reinstaller 2007) is not simply included to make it clear what Toyota was doing that was different. Modern Health Care makes use of every method of production, from pre-industrial craft work to the most advanced manufacturing techniques. Understanding the differences between the methods helps explain why they do not always fit easily together in the day-to-day work of Health Care.

British Manufacturing: The Extension of the Craft Work System

Britain was at the forefront of the industrial revolution, and the nineteenth century saw a massive expansion in British manufacturing. However, many aspects of the organization of emerging large-scale manufacturing firms stayed locked into pre-existing craft work structures. Groups of workers with a craft inheritance, working in expanding manufacturing firms, gained (or maintained) control over key components of the day-to-day operations of the large-scale manufacturing companies. They retained control over the organization of work, including hiring and firing workers (“no ticket, no start,” in the Australian vernacular).

Traditionally, craft work is paid as piece work: you get paid for what you produce. The craft wor...