When Every Minute Counts REACH Air Counts On Lean

When you are in the business of providing air ambulance services, every minute counts and no one knows this better than REACH Air Medical Services. Serving citizens of Northern California since 1987, REACH has demonstrated a capacity for rapid response while performing more than 10,000 helicopter transports and approximately 3,500 fixed-wing (airplane) transports. With an emphasis on pediatric critical care, REACH serves about 3,000 patients a year with about 60 percent of its transports being hospital-to-hospital and 40 percent being 911 scene responses. Working closely with several large receiving hospitals and approximately 200 sending hospitals, the company operates five, fully staffed bases of helicopter operations - manned 24x7, and one fixed wing operation. On board each helicopter is a flight nurse and a flight paramedic. On board the airplanes is a flight nurse and a respiratory therapist.

REACH Air was introduced to lean about three years ago. As with many companies who view lean as strictly a manufacturing concept, its initial reaction was, "how could this benefit us"? Yet, upon her return from a week-long course at the Lean Learning Center (Novi, Mich.), Jennifer Hardcastle, REACH's Director of Program Development, was overwhelmed by the opportunities to utilize lean within her organization.

"After attending the 5-day Lean Experience class, where I was exposed to the foundation of lean rules and principles, I realized how lean thinking could significantly improve our response time and the critical time spent at a patient's bedside preparing for hospital transport. Implementing tools like value stream mapping back at our facility helped us to realize how many broken links there were along the chain between REACH and our hospital customers and how structuring a better flow path could help us deliver faster and better patient care."

Structuring the process

Prior to REACH embarking on its lean journey with the Lean Learning Center, there was no methodology in place at the sending-hospitals to convey how urgently a patient needed to be removed. Relying on lean rules such as (1) structure every activity, (2) clearly connect every customer/supplier and (3) simplify every flow, REACH Air improved the situation dramatically. The first order of business was to study the process flow between hospitals and REACH. Teams were developed both internally at REACH and at the hospital site. "We worked together to come up with standards to define our Level One Acuity patients - those requiring the most urgent care needed," reports Hardcastle. "We classified these into four categories consisting of acute aortic emergencies (for example dissections or aneurysms on the operating table), unstable trauma patients, unstable pediatric patients (whether medical or trauma) and any patient requiring critical lifesaving intervention. For each of these categories, we then identified what staff members can expect when they encounter the patients and the processes involved in emergency treatment. For this level of patient, two, three or four minutes can mean the difference of life and death, so process efficiency through lean thinking took on the highest level of importance."

The teams worked on structuring a process flow for each Level One category and in doing so, eliminated a significant amount of wasted time. Now a facility calls REACH Air's dispatch center and notifies it that it has a Level One request, giving everyone a heads up that this is an urgent case. It activates a plan that launches an aircraft to that facility (Point A) even if a patient's ultimate destination (Point B) is not yet known. Historically, an aircraft wouldn't be launched until Point B was determined, but making the necessary arrangements may involve several phone calls and waste valuable time. By acting upon the fact that in 90 percent of the cases Point B arrangements are confirmed by the time REACH Air arrives on site, the company has eliminated up to about forty minutes of up-front waiting time by launching prior to the final destination decision.

Eliminating waste and increasing efficiency

Implementing lean also helped REACH Air greatly reduce time spent collecting bedside information at a given facility prior to sending a patient to another facility. Before, the verbal report between the bedside nurse and REACH's transport nurse had no structure to it. Hardcastle says, "We were experiencing a disconnect where the bedside nurse was reporting to us what she thought we needed to know, which was then often followed by a series of time-consuming questions that we actually needed to know." A one-page flow sheet listing was created that contained essential information for each Level One Acuity category, making the transfer of information standardized and thus, quicker.

When the sending facility recognizes it has a Level One Acuity patient, for instance, the flow sheet for that particular category is pulled and completed so that when REACH gets to the bedside all of the essential criteria is documented and there is very little verbal reporting. It's preplanned and structured. Plus, no one is guessing anymore about what information is needed - it's all there. Time reduction? Anywhere from three to five minutes.

The action taken by REACH Air that has probably reduced the most waste involves another important bedside procedure and that is medication infusions. The equipment a patient is hooked up to must stay at the sending facility, meaning REACH Air must transfer all the infusions from the hospital equipment to its own equipment. Untaping IV lines and putting in its own tubing is very time-consuming so, working with staff members at the sending hospitals, REACH has trained the hospital staff on how to utilize REACH's own transport infusion pump. Now, hospitals stock a REACH Air pump and all the necessary peripheral equipment so that when there is a Level One Acuity patient, they put the patient on the transport infusion pump and the patient is ready for transport when REACH gets there. This shaved off ten critical minutes.

Achieving sustainable results

"Lean transformation starts with a change in the way everyone thinks about what they do, how they do it and why it matters," says Jamie Flinchbaugh of the Lean Learning Center. REACH Air grasped this concept early on and worked hard to get everyone involved by improving communication and by developing a series of successful training programs. "By understanding the current reality of various activities, identifying an ideal state and using process mapping to better structure these activities," continues Flinchbaugh, "REACH Air has been able to eliminate waste in the form of valuable time. And, using this systematic approach will help them sustain these results."

A healthy solution for the healthcare industry

"The delivery of health care today," says Hardcastle "is chock full of waste. With the lenses of lean now on my eyes, I observe work and activities in a much different way and see that there are tremendous opportunities to eliminate waste and save critical time." Observing work and activities from a lean perspective represents a real mind shift for the medical profession and, according to Hardcastle, it is not common among health care practitioners. She admits that thinking lean is much easier when you're moving a widget through a production line. You can see if a widget is stalled on the line and make process adjustments where needed to improve efficiency. Seeing inefficiencies isn't as easy with patients or lab work or an X-ray request. Yet, anyone who has spent time in an emergency department knows the bottlenecks that exist.

Says Hardcastle, "My own mindset before attending The Lean Learning Center was one of frustration, thinking that little could be done to solve the inefficiencies inherent in our systems. But, now I know differently. By viewing problems as individual process flows that can be restructured, dramatic change is possible."

While Toyota, a master when it comes to lean, has built into their system the notion that people within an organization can suggest, make improvements and bring about change, the healthcare industry is not really set up that way as far as Hardcastle sees it. But it could be that REACH Air -- as part of that industry - is demonstrating just how it is done. REACH was a small organization that has grown into a medium-sized organization, making changes along along the way to achieve significant improvements. Change started at the very top of the organization with REACH's CEO, Jim Adams, who took a very proactive stance with regard to lean implementation. With Hardcastle as the primary lean leader, mentoring and coaching others to foster change, the success of their endeavors is catching on. More and more people within the REACH organization are "getting it" and Hardcastle is seeing new lean leaders bubbling up to the surface all the time. "If we can do it," says Hardcastle, "so can others in healthcare."