Make a Hospital Faster in 5 Days

The following excerpt is from the first chapter of the book "Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, Flawless Healthcare" (McGraw-Hill; 2011). Excerpted with permission from McGraw-Hill. Following the excerpt is a Q&A with Becker's Hospital Review and the book's author, Jay Arthur.

With all the hoopla about healthcare reform, there's one huge missing piece — healthcare is going to have to get dramatically faster, better and cheaper to help pay for the changes. Each of the nation's 5,700+ hospitals must find ways to cut millions of dollars in unnecessary costs over the next decade. This may sound difficult considering that half of all hospitals lose money. Most hospitals exist on a four- to five-percent margin. But Lean can help hospitals start getting faster, better, and cheaper care n just a few days.

A Faster Operating Room in Five Days
Copenhagen University Hospital wanted to reduce the time between surgical operations. With some basic analysis, the team implemented counter measures to save 60 minutes:
• Surgeon draws an "X" on patient's wristband when the patient has been informed about the operation, allowing anesthesia to begin.
• Prepackaged sterile disposables replaced individual disposables, saving two nurses and 30 minutes.
• Standard checklists ensure that all materials are gathered before the operation starts.
• Anesthetic depth was adjusted so that the patient wakes up when the operation is finished.
• Hospital orderlies move patients to recovery immediately.

A Faster Emergency Department in Five Days
Robert Wood Johnson Hospital in Hamilton, N.J, winner of the 2004 Baldrige Award, receives 50,000 patients a year. In 2004, RJW had ED turnaround times of 38 minutes for discharged patients and 90 minutes for admitted patients.

In 1998, RJW offered a 15-minute door-to-nurse and a 30-minute door-to-doctor guarantee. Like Domino's Pizza, if your nurse or doctor is late, your service is free! Patient satisfaction with the ED rose from 85 percent in 2001 to 90 percent in 2004. While payouts for this policy have been less than one percent of ED patients, ED visits doubled!

And because ED visits doubled, hospital revenue increased as well. Seventy percent of hospital admission scores from the ED. Faster turnaround times enabled the hospital to grow by more than 10 percent per ear, requiring the addition of a new nursing wing.

Faster Medical Imaging in Five Days
North Shore University Hospital wanted to improve patient throughput on its CT scanners to decrease length of stay and increase patient satisfaction. Average turnaround time was 20.7 hours and fell to 6.45 hours after the improvement team implemented several countermeasures:
• The requisition printer was relocated in between the two CT scanners, saving more than 6,000 feet per day of unnecessary travel.
• Dedicated CT transporter was assigned.
• An Excel-based schedule was maintained in imaging and viewable by all nursing units (this reduced phone calls and cancellations owing to improper patient prep or availability).
• Instead of a rigid schedule with no room for STAT orders, a "pull" system adjusted the patient transport and scan to accommodate just-in-time STAT scans.
• Contrast preparation was reassigned to the evening shift, refrigerated, and delivered during the transporter's morning run for inpatients.
• One CT scanner was dedicated to complex procedures, and the second was dedicated to routine high-volume procedures to maximize patient flow.
• Staffing was adjusted to demand.

How is it Possible to Get a Faster Hospital In Five Days or Less?
• Gather a team that believes that it is possible to improve patient flow. Some people just don't believe that it's possible; if so, they won't be useful on the team. Don't load the team with skeptics.
Prework: Use pedometers to gather travel data about the clinicians. Identify and collect "wait times" for patients between steps in treatment.
• Have a trained facilitator assist the team in identifying the major delays and unnecessary movement of people or supplies using tools such as value-stream mapping and spaghetti diagramming. Have the team identify possible countermeasures to these problems.
• Implement the countermeasures, and measure results. Implement process-oriented improvements immediately. Move machines or supplies to more convenient locations immediately. Project-manage more complicated changes (e.g. information technology changes, hardware changes, etc.).
• Verify that the countermeasures actually reduce turnaround times. (Sometimes they don't).
• Standardize the improved methods and procedures as a permanent way of doing things.
• Measure and monitor turnaround times to ensure peak performance.


Q: Healthcare reform has sparked a lot of discussion about skills or traits that may come to the forefront in healthcare. Words such as accountability and coordination seem to pepper many of these discussions. This, however, is one of the first times I've seen the concept of speed in relation to healthcare reform. Can you expand on why hospital leaders may want to pay attention to their pace of care?

Jay Arthur: There are three silent killers of patients, productivity and profits: delay, defects and deviation. We know that door-to-balloon time and similar metrics directly impact patient mortality.  Emergency department turnaround times are four hours, according to Press Ganey, unchanged for a decade. And yet some EDs turn discharged patients in 38 minutes and admitted patients in 90. How? Eliminating delays between steps in the process.

But everything needs to be faster. If discharge takes too long, you can't get in to clean the room. If you can't clean a patient room or ICU room, you can't pull another patient in from the ED. If you can't pull a patient from the ED, the ED starts boarding patients. If they board enough patients, the ED goes on divert. Every hour the ED is on divert costs the hospital two ambulances worth $6,000 each or more. In a cardiac care hospital, every fifth ambulance is a heart patient worth $100,000 or more.

And you can't measure the cost to the heart patient who has to travel farther to get the care they need. What if they die en route?

Q: This first chapter outlines some great tips to get a faster hospital in five days. From your experience, what are common roadblocks that may hinder a hospital's ability to accomplish this? How should hospital leaders address skeptics?

JA: Nobody likes to be forced to change. Doctors don't want to change. Nurses don't want to change. Atul Gawande, MD, author of the Checklist Manifesto, says it takes 17 years for physicians to embrace something new. The only way to do this is to engage the doctors, nurses and operational staff that want to make changes. Facilitate them to solve the problems caused by unnecessary delays. When employees figure out the solution, they own it. It takes longer than forcing change, but it works a lot better.

And never engage the skeptics. They are what I call the corporate immune system. They'd rather kill it than change. You may have to fire some reluctant doctors and nurses. They say that science advances "death by death" as the old guard dies out. We can only hope the same is not true of healthcare.

Q: It's easy to link Lean success stories to improved patient experience, which is then linked to a hospital's financial performance. Can you draw more connections between efficiency, speed and a hospital's bottom line? What other costs are often trimmed through Lean?

JA: The 3-57 Rule says clinicians are only working on the patient for three minutes out of every hour. If you've ever been a patient in an ED, you know this is true unless you're having an MI [myocardial infarction]. The 15-2-20 Rule says that for every 15 minutes of delay you cut out that hour, you will double productivity and increase profit margins by 20 percent. In healthcare, that means you can increase productivity by two-, four-, eight-times or more and profit margins by 20-, 40-, 80- or 100 percent. When you do, you'll grow three times faster than your competition and double profit margins.

Robert Wood Johnson University Hospital, winner of the 2004 Malcolm Baldrige National Quality Award, did this. At one conference, employees of the New Brunswick, N.J., hospital confirmed they'd been growing at more than a 10 percent rate and needed to add a wing onto the hospital to handle the load. When you have no delays — what's called one-piece flow — there's no opportunity to miss a step or do one twice (e.g., double dosing a patient). Lean cuts defects by 50 percent just by removing delay.

Q: Some people have called Lean another "flavor-of-the-month" management trend. What would you say to defend Lean against such criticism?

JA: It depends how you implement it. "Flavor of the month" is just another way skeptics "poo-poo" the idea and try to kill it. Since healthcare leadership turns over every three years, the Lean leadership has to come from the informal leaders, not the formal leaders.

When the staff owns it — not the leadership — Lean will stick in the organization. And you only need 4 percent of the staff to own it for it to stick based on studies of how cultures adopt, adapt or reject change.

Q: Some of these steps for a faster hospital are extremely simple. Are hospital leaders surprised when they realize the "bad habits" that have been setting them back are so minor?

JA: Whenever you take a step back and really examine any process, it's always surprising how many workarounds, inconsistencies and other nonsense you discover. All processes grow up in an ad-hoc fashion. Nursing units are designed without nurse input — same with ORs, EDs, etc. Much of the delay, defects and deviation are baked into existing processes and physical layouts. Changing physical space costs money and time, but can save a ton of money. But a lot of changes are simple process changes. I worked with one hospital system that changed the way they handled insurance claims and started saving $5 million a year in denied claims. They implemented the process change over a weekend.

Learn more about Jay Arthur's book, Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, Flawless Healthcare.

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