Issue 10 – May 2012

Issue 10 • May 2012

Niagara Health System Uses Lean Design Techniques in their new Health Care Complex

By Claudia Danyluk and Ammarah Shahid, Lean Facilitators, NHS

The Niagara Health System (NHS) is Ontario’s largest multi-site hospital amalgamation comprised of seven sites serving 434,000 residents across the Regional Municipality of Niagara. In 2009, the NHS began construction of a new health care complex to combine its two St. Catharine's sites, offering acute care and outpatient services to one location, as well as, to accommodate new regional services.

Recognizing the complexity of process planning for moving to a new health care complex, the NHS leadership decided to embrace a Process Preparation (2P) methodology, which is recognized by experts as one of the most transformative and advanced lean tools, to work in conjunction with their operational readiness and transition planning teams. The need for a health care 2P generally arises when creating new processes, managing major volume changes and/or relocating current processes. The NHS leadership recognized that the process planning of the new health care complex met all three of the aforementioned criteria. For example, new processes needed to be developed for the decentralized care stations on inpatient units; likewise, work flows needed to be designed to accommodate the increased patient volume in the regional Mental Health service. All current processes needed to be re-examined to ensure optimal performance in the new space.

More importantly, the 2P technique was selected because it provides a framework for designing future processes based on the ‘voice of the customer’ that, in turn, increases the ‘value-add’ opportunities in the overall patient experience. Furthermore, the 2P methodology promotes creativity and innovation when developing new work flows, while considering people, equipment, supplies, work methods, information, quality, and the physical environment.

To date, the Lean Transformation and Strategy department at NHS has facilitated nine 2P events; these events focused on a range of different processes for the new hospital, such as the medicine distribution system in pharmacy and a central booking process for outpatient services.

Typically, for each 2P event, the preliminary preparation includes using a Sensei’s expertise to develop an A-3 (project charter), which clearly defines the scope of the event, along with the target metrics for the future state. In addition, it entails assembling a cross-functional team based on input from process owners and departmental managers. This ensures that all key stakeholders are represented and that front line workers are empowered to make decisions and influence change in their work environments.

This interdepartmental team then meets for four days and seeks to meet the customer requirements by starting with a blank process development slate to rapidly develop a future process design. This method involves a concept informally known as the ‘seven ways’; wherein, the project team is sub-divided into smaller groups and each group is encouraged to ‘try-storm’ 7 ways of accomplishing the process in question by either thinking at a process or a system level. The Sensei then guides the project team through a rigorous Pugh matrix, which is used to evaluate the proposed alternatives against design specifications driven by the voice of customer, staff, and organization. Ultimately, the alternative that provides the most positive correlation is chosen, and is tested through a mock trial. Toward the end, the team: conducts a gap analysis to create an action plan; creates an implementation plan, and presents their findings to a larger group of NHS staff.

In short, the 2P technique characterizes a paradigm shift for process planning. Unlike the improvement of existing processes sought with kaizen events, 2P events offer the project teams an opportunity to create a completely new process design. Hence, through the 2P methods, the NHS leadership supports its staff to attain a ‘breakthrough’ level of thinking. In fact, the NHS interim CEO often motivates the team members by starting the 2P event with the following words: “Never take “no” from the person who can’t tell you yes”.

Editor's note: The 2P kaizen event is designed to utilize creativity to deliver breakthrough performance. Results from 2P teams include soft savings by reducing distance travelled and decreasing hand-offs. Hard savings can be generated through increased productivity, reduced space requirements, and improved access. Benefits can also be seen in improving the overall patient experience and improving staff and medical staff morale. Patient safety can also be increased by changing a process to deliver safer and consistent care.

Up to 80% of the cost of operations are permanently hardwired into an organization when the process and corresponding footprint of the process are finalized. 2P can design out waste up front saving operational expenses for decades!

Mistake Proofing for Zero Defects

Let’s begin by asking the question, “How hungry are you right now?”  Your degree of hunger varies; at this moment, you may be mildly hungry or starving.  Mistake proofing devices are similar in that they offer varying degrees of strengths, like your hunger.  Some are mild, which could include signs and visuals.  Mistake proofing devices can also be very strong, such as anesthesia equipment that is color coded that can only be connected one way, for example.  Below is an example that helps to better understand Mistake Proofing Devices:

Think of a country train crossing with only flashing lights to warn drivers of on train.  Drive into town, and you will likely find that engineers have designed bars that come down when a train is coming.   The bars are stronger than a flashing light to deter accidents,  but we’ve seen people, perhaps even us, weave around to avoid them.  There are bars that come down that completely block the road; these are stronger yet.  We can, however, totally mistake proof the tracks to prevent collisions by building a bridge over the tracks.  Now, neither traffic nor train have to stop, and the chance of a big mistake occurring is eliminated.

What determined the strength of the device? Here, it was the cost of the device (lights, a bar, or a bridge) versus the volume of potential incidents.

Let’s squeeze one more lesson out of the train intersection.  Imagine the department of transportation decides to bring everyone from the community in for an education session on how to cross tracks, sending out follow up emails to gauge understanding.  Our reaction to team’s solutions to teach awareness should be as strong as our reaction would be to the train crossing education; it’s the weakest solution one could generate short of doing nothing. Yet this is the most common approach to problem solving.

You may face the dilemma of finding a mistake proofing device that guarantees elimination of errors.  The web site mistakeproofing.com has a book titled Mistake Proofing the Design of Healthcare Process available to download for free as a PDF file.  I'd suggest browsing the many pictures the author has included to get an idea of mistake proofing devices in use in healthcare today.  As you take in these examples, you'll find yourself referring to them and applying the concept in new areas of your hospital.

Mistake proofing is our only hope for zero defects within healthcare. As an industry we rely way too much on memorization, counting, and training to deliver high quality and safety. The concept of mistake proofing is the only way to deliver error proof safety and quality. Include this thinking into your lean processes and standard work.

Lean Leadership - Two Types of Governance are Necessary

Enterprise Wide Transformation Governance

To effectively implement the Toyota Production System across an enterprise you need an effective steering committee. The steering committee should be comprised of the key change agents within the organization. This powerful guiding coalition can come from management and staff and consists of ~ 10 people. The enterprise steering committee is responsible for at least eight main areas.

1. managing the pace of change
2. selecting the right areas of focus
3. ensuring value stream improvement
4. ensuring standard work is followed for improvement
5. managing the communication plan
6. developing people (improvement capabilities of the organization)
7. managing the improvement measures (process and outcomes)
8. removing corporate barriers

Value Stream Governance

Each value stream will need to have a governance structure. The value stream makeup will consist of the value stream manager, key process owners, and support process owners, and the lean expert. This committee may only include 3-5 people. Value stream governance is responsible for the following:

1. managing the value stream improvement plan (priorities and intensity)
2. ensuring everyone in the value stream is participating in improvement
3. ensure improvements are sustained
4. ensure improvements are sustained
5. ensure improvements are sustained (get the picture)
6. follow up on variances from the visual management system
7. ensure resources are allocated to localize improvement
8. hold staff accountable to standard work

If you are not getting the results you are expecting from your improvement efforts, check your governance structure. If you are not providing effective (or any) governance to your improvement efforts, you likely are skipping some important steps in the transformation process leading to spotty and un-sustained results.