We are now bringing the benefits of Transformational Lean to the healthcare industry. While there are many differences between healthcare and manufacturing, there are also a great many similarities. It is this realization that has motivated us to help address the dual need for improved quality and cost control within healthcare.

Our new Healthcare Transformational Lean division brings a very unique approach to traditional process improvement, combining a suite of advanced technologies with consulting services aimed at accelerating the creation of value in hospitals. The result is improved patient safety, operational excellence, and better financial performance.

The Transformational Lean Approach

At the core of our methodology is multi-disciplinary problem solving tailored to the unique needs and organizational readiness of the hospital, and delivering sustained improvement by enabling self-sufficiency from the executive suite to the front line.

Transformational Lean focuses on four key areas:

• Technology: Real-time monitoring of supplies, equipment, & people, patients, staff, vendors; interface management; and data mining to deliver business intelligence and business analytics
• Complexity Management: Focused, collaborative effort to streamline supplies, systems, and staffing models to comply with hospital metrics and regulatory standards
• Process Optimization: “End-to-end” process redesign to optimize material & patient flows, increase percent of caregiver time available for patients, and minimize waste
• Supply Chain Excellence: Systematic replenishment of inventory in all areas of a hospital network to not only minimize par levels, but also ensure accurate & timely delivery of required supplies, reducing or eliminate over renting or buying of equipment

Transformational Lean starts with a deep dive assessment into the hospital’s business challenges, with ROI modeling, defining the organization’s maturity model and running simulations.

Once the hospitals understands what can be achieved, our onsite team can manage anything from a department project to incorporating Transformational Lean throughout the facility. Our goal is to create a program on any scale that is not only successful but sustainable for years to come.

Healthcare facilities are often overwhelmed with equipment and supplies because they do not have the processes in place to review and monitor equipment. Items are kept around “just in case” they might be needed sometime. But this approach does not proactively prepare the hospital to efficiently respond to patient needs.

When I’m consulting with hospitals, I always ask what’s the best way to provide patient care; there are better solutions than using a piece of equipment that has been stored for a long time and may even be out of its preventative maintenance cycle.

The first step to cure hospital hoarding is as simple as looking at the lean process of 5S, which stands for SORT, STRAIGHTEN, SHINE, STANDARDIZE and SUSTAIN.

To get started, form a team that agrees to the process and choose an equipment room. You’re now ready to start the SORT phase. As a group, identifying each item in the room, and answer questions such as:

1. How often is the item used?
2. Is there another device that can be used for the same procedure or process?
3. Is the equipment functioning and under PM process?
4. Are all the parts available for the equipment?

If the answers to these questions point to the item being redundant, unusable or out of date, identify it for REMOVAL. If there are additional questions to answer first, or if the item needs to be reviewed with management, identify it for REVIEW.

Items that are actively used are ready for the STRAIGHTEN phase. By labeling and designating specific locations for the remaining equipment, you will make it easier for staff to find equipment and return it to its proper location. Have fun with this part. Use color, pictures and labels to clearly identify the equipment and where it lives.

As you go through all the equipment in this methodical manner, you will find that you have removed items that are not really needed, and also identified equipment that requires maintenance to be safe for patient care.

Where does SHINE come into this plan? It is also critical to clean not only the equipment room but also wipe down all equipment so that it is ready for use. If there are supplies that are used with the equipment, clearly identify where the supplies can be found. Ensure the EVS knows the appropriate cleaning process in this room, and develop a plan for quarterly terminal cleaning of this space.

The next two “S” steps are critical. STANDARDIZE is not only about labeling but also educating staff about the standard work related to the equipment room. There should be a clear communication to the entire department about the changes in the room, and the expectation that equipment must always be placed according to the plan.

In order to SUSTAIN, you need to ensure that the standard work is being followed. Once this room is done, you should schedule monthly and quarterly gemba walks. Is equipment where it belongs? Are all the labels and floor markers (tape showing locations, etc.) in the correct place? Is there dust/dirt present? This is critical to ensure that the process is being followed.

Although the 5S team has to dedicate a lot of effort to start the improvements in the target equipment areas, there is a huge reward. The entire team will benefit from being able to locate equipment and know that it is ready for patient care! Old items that are no longer needed won’t be taking up precious space.

There is another critical group that also has to be part of this team effort: parents and family. An aware parent can prevent an infant abduction attempt, or provide vital information on family conditions that might indicate heightened risk for a pediatric patient (custody disputes, behavioral issues, etc.).

The key to involving parents in the security of their child is education. While approaches differ, most hospitals cover these basic points:

• Rules for transporting patients: when and how patients are moved within and beyond the department
• Staff ID system: how to identify hospital employees, and the nurses authorized to care for their child
• Hospital routines: learning the nurses on each shift, schedules for feeding, bathing, etc., and rules on access to the patient care area
• Tests and procedures: what to expect for their child, and who to ask for information
• Family background: encouragement to provide information that could indicate additional risk
• How the system works: basic information on the patient security system, and the rules to follow

This information can be conveyed in a variety of ways: in printed pamphlets, in-room posters and one-on-one. It can even be covered in pre-natal classes. The more often the family is exposed to the message, the more likely it is to sink in.

As a final note, Stanley Healthcare Solutions has a range of patient education materials and other items for all of its Patient Security products, offered as part of its By Your Side customer support program.

 However, now is the time to begin planning for implementation, because ICD-10 presents hospitals with an opportunity to transform their operations and improve patient care; ICD-10 will touch every facet of the care spectrum – EMR, budgeting, reporting and payers.

 The first critical step is to complete a readiness assessment to properly gauge the impact to your organization. ICD-10 is therefore NOT solely an HIM or IT project!

 Where Do You Begin?

ICD-10 codes will provide greater specificity for diagnosis and operations.  To fully assess organizational impact, the following questions need to be answered:

• Who will be the driving force for ICD-10 in your organization? Who in the organization fully understands ICD-10? Do you have a strategy and governance structure in place for this multi-year engagement?
• Who are the internal vendors who can help properly implement ICD-10? The organization will need to look at workflow integration, internal operation/reporting changes and system upgrades. Have you prepared a list of contracts and assessed how they utilize your data?
• Who are your business partners and vendors, and what is their preparedness? (MEDITECH, Epic, etc.)
• There will be an expected 20% productivity decrease during the implementation phase. Will you need additional staff to maintain current activities, and if so, in what areas? Resource allocation needs to be accounted for in budgets and addressed across all areas including revenue cycle, clinical, staff augmentation, contingency plans and financial monitoring. 
• What other strategic initiatives will be occurring for the enterprise in 2013 (i.e. acquisitions)?  All future initiatives need to be accounted for in strategic planning.
• What financial gains will result from ICD-10? Similarly, what might be financial problem areas for your organization?
  • ICD-9 codes are mapped to ICD-10 on the CMS website. It is not a one-to-one mapping, however, which will lead to redistribution of payment across DRGs. You will need to understand what the financial impact will be!
• What is the current relationship with physicians? Designating physician champions will be a critical component to success. What is staff knowledge of ICD-10?
• Coding competency: what preliminary refresher courses are needed prior to launching the ICD-10 initiative within your organization?  Do you need outside resources to complete?
• Assess changed management process: are there lengthy approvals required for changes? Should this process be re-evaluated for ICD-10?
• What type of patients do you see? What types of diagnosis are you coding on a routine basis?
• How does data flow from IT, where is it stored, and how is it used? What reports currently include ICD-9? Will you need outside resources for report writing?
• What ad hoc systems need to be considered? Many clinical teams have ad hoc systems that have codes that are not commonly seen in health information management systems (i.e. LAB). Who owns these systems? This is a huge operational concern. End-to-end operational testing will be required for each area — patient access, case management, clinic documentation, and quality across the entire organization!!
• How will your organization accommodate both ICD-9 and ICD-10 codes, post Oct 01, 2013? Who needs to be involved with this process / decision-making? Dual systems will have to maintain collections and month-end reports to accommodate different data elements.  Both databases will be required to provide year-end reports.

Where Should You Be Now?

At the stage, your readiness assessment should be complete, with strategic project planning in full swing. The clock is ticking, and the time to start work is now!

The definition of room turnover is the time between wheels out and wheels in to the operating room. This timing is critical in order to ensure that the operating room is utilized to maximum capacity and that the schedule is being managed efficiently.

Recently we began a project to reduce turnover time, which stood at 49 minutes, at a client hospital. The first step was value stream mapping, followed by the creation of swim lanes to identify not only what needed to happen during the transition between patients, but also who would be responsible for these tasks.

We ultimately identified 11 different positions/functions that help to ensure an efficient room turnover. We also identified that the process starts even before the patient is actually wheeled out of the room.

Once the process was mapped out, we identified constraints that impact a successful room turnover. We assigned a person to own their process swim lane and they worked with their peers to identify opportunities for improvements. We then did individual training with each team, as well as delivered a clear message about the roles/responsibilities for each person involved.

We have already seen improvements in room turnover time, and we are now moving forward with communication improvements in order to reduce waste in phone calls. Our goal is to reduce the turnover time to 30 minutes over 6 months – a reduction of 19 minutes. Without having a clear picture of the process and where wasted effort occurs, it would have been difficult to achieve change!

These systems continually monitor battery level in tags, device status and other aspects of the system, and generate automatic alerts to warn users of a problem.

However, it is still necessary to implement a regular process of testing and drills to ensure that the system works at an optimal level. These activities really apply to patient security systems from all manufacturers.

Testing

All aspects of the system’s operation should be tested regularly. Test each exit with a real tag, to check that alarms are properly generated in the software. It’s important to look at peripheral equipment as well, like magnetic door looks: do they engage when a tag approaches the door? What about any sounders or other annunciation devices? Do they activate as expected during an alarm?

Also review coverage of receiver devices, to make sure that tag signals are detected throughout the protected area.

The system database is a rich repository of information of what has happened in the system. Get into the habit of running reports on alarms and other events. This can help show up problems, like a high number of nuisance alarms on one particular shift – an indication that refresher training may be needed.

Drills

Many hospitals run regular drills to test how staff members will respond to a real incident. After all, in the end the system is only a tool – it is the people who use it who make the real difference.

Try to make your scenarios as realistic as possible – for example, trying to smuggle a “baby” out in a large handbag. If possible, it should start as a surprise, although everyone needs to be informed that it is only a drill. You don’t want the police showing up on you!

It’s also important to involve all parties in the testing – Nursing, Security, anyone who has a role to play in patient security (and that should be just about everyone). In all likelihood, the pretend abductor will be caught before she/he gets off the unit. But your policy probably has backup procedures in case an abductor gets passed this first line of defense – so keep the drill going to test each layer in turn.

Finally, a debrief immediately after is the best way to captures ideas for improvement, which you can then use to further refine your procedures. You’ll be even better prepared should you ever have to deal with the Real Thing.

In order to meet the business and clinical objectives and promote adoption, the key stakeholders should come to the table with suggestions or decisions regarding the EHR and processes.  In addition, physicians will have questions about the impact on their business:

• Will it offer the appropriate options for the type of practice (specialties express more concern)?
• Will the clinical workflow support productivity?
• What will the impact be on practice management and billing?
• Will this lock the physician into one particular hospital or will it meet the needs when practicing at more than one (non-related) facility?
• How will it impact the patient view of the practice?
• Who supports the technology needs of the practice?
• Is it cost effective?
• Will it allow me to meet Meaningful Use?
• What happens to the records if the physician is no longer associated with the enterprise?

The sharing of information to improve quality of care and decrease cost is reliant on aligning factors of the EHR.  In this instance, a healthcare system needs to match up information between the hospital and physician offices.  These factors differ between inter-enterprise (owned) and intra-enterprise (affiliate) practices.  With all of these objectives, questions and variables to consider, the challenges are numerous.  Here a few:

• Support of disparate vendors over time
• Compliance – the ONC and CMS requirements change and increase rapidly, long term data standards changes, IT standards (security, bandwidth, certifications, disaster recovery, storage)
• Lack of clinic resources – human and financial
• Specialist preferences
• Lack of true vendor interoperability
• Long term support – maintenance of systems with new releases, end user change requests and more
• Ongoing provider mergers, acquisitions or losses
• Workflow changes
• Culture Shock

As all of these challenges have been embraced, best practices have emerged. Before initiating consulting services, thoroughly research firms’ experience with inter- and intra-enterprise implementations. Issues are going to arise and it’s important to identify and address the risks ahead of time. With proper guidance and strategic planning, a hospital will be armed with a roadmap that will win the commitment of leadership and physician practices in the community.

Risk Management brings a unique perspective. Its specific expertise is in assessing risks and putting in place appropriate measures to counter them. It can therefore help answer the tricky question, “Are we doing the best we can?”

Risk Management also is used to the process of continual assessment of current practice to make sure that it is both effective and reflects industry best practices. It is human nature to fall into an accepted routine without thinking too much about it; in fact, we need routines to get things done efficiently. But it is Risk Management’s special task to make sure that all routines don’t just become a matter of habit and rest squarely on regularly reviewed best practices.

Patient security and safety systems, like our Hugs system for infant protection or Bed-Check fall monitors, are often chosen, purchased and administered at the departmental level. We encourage a high degree of ownership by the clinical staff, because it is nurses who use the system day-in and day-out.

But at the same time, the clinical staff needs support to make patient safety and security as effective as possible, and help drive a process of continual improvement. Risk Management is a natural leader in this effort.

One of the most discussed sessions at this User Conference was on security for NICU patients, presented by Tracey Meyers, RN, the NICU Manager at Alegent Health Bergan Mercy Medical Center in Omaha, NE.

For a long time, NICU babies were considered at such low risk that no special measures were required. Many are on ventilators, which themselves alarm if disconnected, and with central nurseries with controlled access, all the babies could be easily monitored by the nurses on duty.

But as Ms. Meyers discussed in her presentation, this picture of the NICU is starting to become out of date. Many hospitals, like Bergan Mercy itself, have gone to private rooms in the NICU. With six or a dozen rooms, down different hallways perhaps, “keeping an eye” on patients simply isn’t possible. Not to mention that this kind of layout usually involves more possible exit routes: stairwells, service elevators, etc.

Beyond that, it is a false assumption that no one would be interested in abducting a “preemie.” Once the infant reaches open crib status and no longer requires a ventilator or other assistive device, he or she is just as likely a target as a baby in the wellborn area.

These considerations have prompted Bergan Mercy to extend its infant protection system from the wellborn area to the NICU. It’s a stance that many other hospitals are also taking.

You can read here about another hospital using the Hugs system to protect its NICU babies.

*Image courtesy of Alegent Health Bergan Mercy Medical Center

We thank them for working hard to answer the phone on the first ring, and to turn standard quotes around in just a day. Customer service’s job is to “delight” the customer – to help our customers weed through a sea of promises made by every supplier, all touting the same message.

The real difference between companies, after all, starts to show as soon as the customer finally makes that phone call or sends that quote request – that moment when your “prospect” suddenly turns into your judge.

This scenario could be applied to the nurse/patient relationship too: a nurse is just as much a customer service agent as she is caregiver. Her job is to delight the customer. Case closed. She needs the right supplies, the right resources, at the right time in order to serve her customer to her fullest potential. We all have a role to play and our role as supply chain professionals is to ensure that our nurses aren’t wasting time searching or waiting for valuable supplies. Our role is to help our nurses answer the call on the first ring and to deliver a response in the appropriate time frame.

While there is a National Nurses Week (May), it’s always a good reminder to say “thank you” to those folks on the front line in healthcare, the men and women answering the call. When you get it right with your customer, you have a champion to share your story and share in your success.