A Slow and Steady Approach Results in Faster, More Reliable Processes

When it comes to achieving sustainable performance improvement that cuts across all divisions, the prognosis at Northeast Health looks good. Thanks to a slow and steady approach to lean implementation.

Northeast Health was formed in 1995 with the merger of Samaritan Hospital and The Eddy, which offers senior care and services. Albany Memorial Hospital joined the network in 1997. Today, the system provides care to approximately 350,000 people with an array of services. From hospitals, diagnostic services, and rehabilitation to nursing homes, home care and retirement living options, Northeast Heath, headquartered in Troy, New York, reaches out to 15 counties and employs more than 4,000 people.

In 2003, Northeast Health began investigating the idea of initiatives to improve processes throughout the organization. Its Board Performance Improvement Committee was asked to research options and examined a number of them including Six Sigma, the Baldridge Award, and ISO 9000 before deciding to pursue lean. Lean was chosen because of its simple, straightforward approach of focusing on process standardization -- something that Northeast Health thought would differentiate it from competitors.

After sending out RFPs to various lean providers, the decision was made in early 2004 to work with the Lean Learning Center of Novi, Michigan. “We liked the fact that partner and co-founder, Andy Carlino had healthcare experience,” explained Tricia Brown, vice president of corporate affairs. “And, because they helped us see how applicable lean was to specific projects as opposed to other groups whose high-level approach we just couldn't get our arms around.”

In conjunction with this decision, Northeast Health made another important one. “We understood that implementing the initiative with a one inch deep, 100 foot wide approach would mean proceeding at a slower pace,” explained Brown. “But it would give us the opportunity, within our budget constraints, to ultimately touch a larger population of the system.”

Scoring quick yet decisive wins

Northeast Health rolled out its lean initiative in 2004 with the intent of giving people a “taste” for lean. Carlino introduced the principles of lean to 35 top managers in a two-day session. Then, the Center's Sr. Consultant, Paul Mullenhour, came in to conduct four kaizen events that first year -- two in the acute care hospital, one in home care and one in the nursing home division.

Focusing on targeted issues in a particular unit or department, team members mapped out specific processes step-by-step, breaking down every task in detail. Goals were established, root causes examined and ways to save time and eliminate waste were identified in order to improve process flow.

A kaizen in the patient care division, designed to streamline prep time in ambulatory surgery, proved successful because of its narrow focus and well-defined scope. The key goal was to decrease the amount of wait time in pre-surgery by one half hour. Post-event review showed that the goal was not only met - it was sustained in nine out of nine surgeon-identified specialties. Another early kaizen in the nursing home division identified yet another opportunity to save time and its goal was also achieved.

In a third 2004 kaizen - this one at Samaritan Hospital - the team focused specifically on decreasing operating room turnaround in GYN cases where a physician performs two surgeries in a row. Pre-kaizen data showed that the average turnaround time was 21 minutes. Process mapping indicated that it could be done in 13.63 minutes for more than a 30% improvement. When the new process was put in place, the aggressive goal was not quite met … however, by achieving a 20% gain in turnaround time savings, the team could still call the event a success

These early victories not only gave staff members a taste of lean, they made believers out of them. One was Patrick Archambeault, a supervising community health nurse who recalls, “The kaizen was a lot of work but it was well worth it. There is such a need for this process. It brought us together as a team to share ideas, which is wonderful. I wish we had done it a long time ago.”

Reaching out … touching more

In 2005, Northeast Health branched out a bit more with its initiative, conducting a total of 11 kaizens that touched even more areas of the Northeast Health system. In a residential services lab kaizen, the expected measure was bold - no missing labs in patient charts and 100% processing and reporting of physician-ordered labs. How did they do? A three-month sampling at 3 facilities and a full-year sampling at another showed only 2 missing labs at one facility. Almost on mark but not quite, so a new action plan was put in place. During that week the IT department developed a new way to use the system that enters and checks lab results. And, a closer relationship between two divisions - in this case the nursing home and Samaritan's lab was forged.

Another kaizen team in the community services division set a goal to meet promised (expected) home medical equipment pickup dates. Pre-kaizen data showed an on-time pickup 63% of the time. Post-kaizen data showed an average on-time pickup of 84% for 9 months in 2005. 2006 data continues to sustain the results at 92%. Also, driver productivity increased from 1.16 average deliveries/hour in 2004 to 1.21 in 2005.

“The kaizen tool has worked very well for us,” says Brown. “Even negatives have been positive. Sometimes our events seemed a bit too big. Like the one where we had all four nursing homes involved. In it, we had to overcome hurdles because of the size of the group. But, in the end, without what I call a ‘world hunger’ approach, I don't think we could have standardized the process across the whole division so quickly.”

Another step toward lean implementation was taken when Tricia Brown was sent to the Lean Learning Center's five-day Lean Experience in Novi. Here the objective is for participants to internalize lean through personal experience and application. As Andy Carlino explains, “Our form of instruction is certainly not the norm. Lean concepts are taught through discussion and hands-on discovery, not lectures.” A popular part of the experience involves the airplane simulation exercise. On day two of the session, student groups build model airplanes. Typically, each group only builds one airplane in the allotted time. The second time around -- at the end of the week-long session -- using lean methods, tools and applications - most groups build at least nine.

Brown found the “learn, apply, and reflect” aspect of Lean Experience to be just what the doctor ordered. “The goal is to send participants back as walking examples of lean thinking and I couldn't wait to get back to share the experience with others.” As a result, the lean team is growing all the time. In addition to Brown and Dr. John Collins, chief medical officer, four people have attended the Center's Kaizen Boot Camp class in order to learn how to plan and facilitate their own kaizen events.

Easy-to-digest learning

Another key component of lean implementation is the Lean Learning Laboratory, a place where small groups learn, practice and apply lean rules and tools. The lab consists of orientation meetings, module training by Brown and Dr. Collins, post-training and reflection. Subject areas include Scoreboards; Waste Walks; Five S's; Standardized Work and Problem Solving. In 2004, the Lean Learning Center helped Northeast Health launch its first Lean Lab in the central intake department of its community services division. Three additional labs are now up and running -- one in the pre-admission testing area at Samaritan Hospital; one on the floor of a nursing unit at the Eddy Ford Nursing Home and one at Northeast Home Medical Equipment.

“The labs are perfect for learning about lean tools in an easy-to-digest way. They've helped us realize -- and sustain - real, concrete achievements,” says Dr. Collins. “Our people are going out into a particular unit, applying a lean concept that has just been learned, figuring out a key improvable and then tracking it in weekly or bi-weekly huddles.” Adds Brown, “The labs have been wonderful. Though they take time and they're concentrated on a little department we are really seeing groups that grasp these ideas and start using it day to day as they question the waste in their area and work on eliminating it.”

Reaping the results … spreading the word

While financial-savings was not the primary motivator of the lean initiative, significant dollars can be attached to the improvements Northeast Health has made. “What really is amazing, though, is the time-savings we've been able to attach to lean,” says Trish Brown. “This has been huge in terms of our being able to improve the service we deliver to our patients and residents, not to mention the improved quality of care.” Dr. Collins is quick to point out that employee development has been key as well. “Many people - over 250 - have been touched by lean now. And rising lean stars are being identified all the time. We're in this for the long haul. And, educating even more employees - particularly providing a higher level of knowledge to a broader base of senior people -- will help us realize even greater results in the future.”

“The hardest part of lean is sustaining it over time,” admits Brown. Which is why the action review process and system-wide communication are so important. The kaizen teams get back together after three and twelve months to discuss key measures met, barriers encountered, successes to build on and weaknesses to improve on. One-page kaizen summaries are prepared and sent across the system.

Affiliate newsletters record lean successes, progress is discussed at staff meetings and senior leaders, including Northeast Health CEO, Dr. James Reed attend kaizen events regularly. Northeast Health is also working on a quarterly publication, called the “Green Book” that pulls together the various performance improvement initiatives being undertaken across the whole system. “It's like a three-legged stool that will include patient satisfaction data, the results of a series of patient safety metrics and results of our quality initiative, including lean,” says Collins. Eventually this information will be shared throughout the organization.

Balancing rollout with reality

Northeast Health has been heating things up a bit in 2006, with new kaizens and learning labs. And, in the next rollout phase, education will play an even greater role in growing the culture of lean. “What we're facing now is that as more people see what lean tools can do, they want to do more with them,” says Collins. Which is why Northeast Health is working right now on a plan that will help strike a balance between demand for lean and its supply of resources. “We all seem to agree that kaizens alone won't do it,” says Brown, “and learning labs are valuable for helping us in specific areas only, so ultimately we will have to broaden our approach.”

Admits Carlino, “Northeast Health's growing commitment and experience base means that they don't need us as much. And, that's a good thing.” Back in 2003, the board was grappling with the what and the who of lean implementation. Now the big question for senior leaders is, “How fast can we afford to go?”