Fishbones

To follow up on yesterday's post about the CC6 Lean team, I had a few minutes today to drop by just as the group was getting engaged in fishbone diagrams. These are used to brainstorm in more detail the nature of major problems, looking at their components and then asking the "five why's" to conduct a root cause analysis.

As I walked into the room during a break, a couple of people mentioned to me that the morning session had been a lot tougher, emotionally, than yesterday's current state analysis. This is a common stage in the Lean process. It is relatively easy to map out the current state. When you start talking about why it exists, it is hard not to blame someone else in the room or someone who is not in the room. "If [name] only did this differently, we could solve the problem," is the common refrain I have seen in other rapid improvement events.

But, the idea of Lean is to focus on the problem and not the person. This is not about blame. It is about a workplace environment that has evolved over the years -- full of work-arounds and inefficiency and waste. By the time I left, the group was again smiling a bit more and collaborating on how to analyze the situation. Later, they will invent countermeasures to help undo the waste, setting goals and targets and timelines for the next steps.

Here is a short video about fishbones to give you a sense of the concept and how it progresses. Jenine Davignon from our business transformation group is leading the class. If you can't view the video, click here.

Wow, they work hard!

The roll-out of Lean at BIDMC continues throughout the hospital. A current project is to redesign the work flow on "CC6," one of our busiest medical/surgical floors. Although the staff has been working on this for several months, it can be difficult to find time during the workday to make improvements when nurses, patient care technicians, and others have full patient assignments. So, this week, we have taken two days aside for an improvement event, during which the staff will have dedicated time to look at their processes and experiment with improvements.

I dropped by for a short time today to watch people outline the "current state" of their work flow. A person in each job category prepared a step-by-step itemization of their daily routine. I offer a videotape of sections of this below. In order, you will see Stacey Adamson, physical therapist; Dawn Castro, resource nurse; Mike Crowley, unit assistant; and Laurie Phillips, case manager. You will also briefly see Jenine Davignon, a management engineer from our Business Transformation office, and Allison Wang, a college co-op student in that office. And finally Oscar Juarez and Sandra Espinosa, being reminded to post lunch breaks as part of a busy day in the work flow of a patient care technician.

I was impressed by the complexity of each person's job. I also began to see, as they presented their daily work, opportunities for reducing waste and improving the work environment and patient care. The team will undoubtedly find many more of those opportunities during this two-day session. If I can drop by tomorrow, I will report back to you.

If you cannot see the video, click here.

College student cleans up

Continuing our short series about summer student projects, here you see Aviva Hamavid, a college student intern, participating in our freecycling program. This is based on the idea of a swap shop. You bring in office materials you don't need, and other people take them.

“The idea is to take existing supplies which, for one reason or another, are not being used and give them a new life where they can be used,” says Aviva's supervisor, BIDMC’s Sustainability Coordinator Amy Lipman. “Sharing these items keeps them out of landfills and helps save money throughout the medical center.” We do this twice a year, and the events have made paper, hanging folders, file folders, binders, unused toner cartridges, envelopes, labels, desk organizers and other useful office items available for free to all staff. (Regular readers will remember that I also ran my own version of this last year.)

You see Aviva and Amy in action in the video below, where they have set up the freecycle station in a corner of our cafeteria.

If you cannot view the video, click here.

Point-Counterpoint

A recent Boston Globe op-ed by Suzanne Gordon argues in favor of state-mandated nurse staffing ratios for hospitals. A response to this was submitted as a letter to the editor by our chief nursing officer. Here are her thoughts:

We can all agree that more nursing time spent directly with patients results in better patient outcomes. But mandated nurse to patient ratios, which Suzanne Gordon advocates in her Aug. 5 op-ed “Critical care,’’ are the wrong way to achieve this goal.

Those of us applying proven improvement methods in health care, such as Lean and Six Sigma, have learned what the manufacturing world has long known. We need to free nurses from the administrative burdens, inefficient activities, and wasted steps that do not directly add value for patient care.

In an environment of rapidly expanding health care costs, legislatively mandated nurse to patient ratios are unsustainable.

Yes, we need more nursing time spent directly with patients. But we must achieve this by aggressively applying improvement techniques to remove waste from our workflow. This is the only sustainable way to both control costs and improve patient safety.

Marsha L. MaurerSenior vice president, Patient Care ServicesChief nursing officerLois E. Silverman Department of NursingBeth Israel Deaconess Medical CenterBoston

AARP confirms value of mystery shoppers

I have written here once or twice about our mystery shoppers. Here's a new article in the AARP Bulletin on this topic.

As noted in this story, we continue to find this a very important way of meeting our patients' expectations:

Sherry Calderon, manager of ambulatory services at Beth Israel, says: “I really feel like this kind of regular checking has driven change here that nothing else has.”

Toussaint and Gerard tell us how to get on the mend

John Toussaint and Roger Gerard have published a book entitled On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. Ordinarily, you would be well advised to be skeptical of anyone promising revolution and transformation, but not here.

Here's an excerpt from the introduction:

With few exceptions, [government policy] debaters assume that healthcare costs are fixed, that America's proud history of medical care and innovation comes with a staggering bill.

We know different.

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses -- all of healthcare -- must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.

And then, they go on and explain how to do this.

You can get a sense of the message in this video produced by the Lean Enterprise Institute, which also published the book. If you can't see the video, click here.

Lean is for bakeries, too

There is a problem once you learn the Lean philosophy and techniques: Every setting prompts you to imagine how much better it could be if these principles were adopted.

Earlier this week, a friend gave me a sample of some marvelous cranberry bread from a new bakery in Wellfleet, PB Boulangerie. She warned, though, that the place has long lines and that I should be prepared to wait, unless I arrived at the 7am opening time. I arrived at 7:05 and found a line of 20 people. Here is a picture of the ones behind me after I had been there ten minutes.

Now, it is summer on Cape Cod, and who really cares if you have to wait? You meet people from all over and compare notes about beaches, restaurants, and the like. But, then we noticed that the line was scarcely moving. Earlier customers set up their coffee and pastries at a nearby table, and they were practically finished eating by the time I approached the front door.

Once inside, the problem was made evident. There were plenty of serving people (four), but the bakery was rife with batch processes. Two people were in charge of taking orders for bread and pastries; one person was in charge of coffee orders; and one person was the cashier. After the bread person took your order and put it carefully in bags, s/he would place the order on a low shelf, under the counter near the cashier. Meanwhile, the coffee person would hand you your coffee directly.

By the time you got to the cashier, she had become a bottleneck. She would reach under the counter and grab the closest order, and lift it up and place it on the counter and say, "Did you have two baguettes?" and you would say, "No, I had the brioches," and she would bend down and replace the first order with your order. Meanwhile, some independent process would be going on for the coffee.

The person next to me was a process engineer, and so you can imagine the conversation we started to have. What if there had been a continuous process, with visual cues, all focused on the needs of the customers? The possibilities were endless.

In this case, though, the elapsed service time, start to finish, was 55 minutes.

But, here are the almond paste and raspberry brioches, along with the cheese bread and cranberry bread. Worth the wait!