Leaning Towards Efficiency

At Meadows Regional Medical Center (MRMC) in Vidalia, Ga., it is my goal as CEO to have our employees think about our business holistically rather than just focus on doing their jobs in silos. In so doing, I believe we can increase patient satisfaction, reduce costs and decrease the opportunity for errors.

In 2005, we had the opportunity to do just that by taking traditional manufacturing principles and applying them to healthcare. Matt Oxley, one of our trustee board members and an entrepreneur outreach specialist with the Georgia Rural Economic Development Center, learned of a team from Georgia Tech that was doing work in lean manufacturing — a management principle that can be used to reduce cost by eliminating waste — and had the opportunity to go to one of the seminars and experience the simulation program. When he described the experience to me, we collectively thought that it had applications in healthcare.

Matt identified resources to bring lean specialists from Georgia Tech's Enterprise Innovation Institute to Vidalia to teach the simulation to a selection of staff. From the simulation, we chose a project that we thought could produce some significant results. After consulting with Frank Mewborn of Georgia Tech, we decided the most logical place to start was the emergency department (ED) due to its high visibility in the hospital and within the community.

MRMC is an 87-bed acute care hospital with a 35-bed skilled nursing facility and experiences over 27,000 ED visits per year. The ED houses 13 beds in 12 rooms and is typically staffed in staggered schedules with six RNs, one physician and one PA (two between the hours of 10 a.m. and 10 p.m.). The hospital primarily serves two counties with a combined population of approximately 40,000.

With approximately half of our patients coming in through the ED, it is one of the most strategic entry points for healthcare from the patient's perspective. Of course, emergency room overcrowding, long wait times and patient satisfaction are all nationally known issues. This was our best opportunity to apply lean principles quickly.

The Road to Lean

Based on continuous improvement systems developed by the Toyota Motor Corp., lean manufacturing processes cut waste, reduce production time, expand capacity and lower costs. There is also a focus on improving workflow. In the book, "The Toyota Way," the principles of lean are outlined as follows: Base your management decisions on a long-term philosophy; the right process will produce the right results; add value to the organization by developing your people and partners; and, continuously solving root problems drives organizational learning.

The lean team at Meadows developed 44 action items for reducing lead time to admit, treat and discharge a non-critical ED patient, 18 of which were determined to be low cost and high impact.

Peggy Fountain, our ED director, served as the point person for the lean implementation. Her primary issues were with bottlenecking, turnaround times, decreased satisfaction and overworked nurses. In June 2005, Georgia Tech's lean specialists conducted a 3-day lean overview workshop and value stream mapping event where we developed diagrams to analyze the flow of materials and information required to bring a product or service to a consumer. In addition to Peggy and myself, workshop participants included the ED nursing staff, an ED physician, the radiology director, laboratory manager and business office staff.

I firmly believe you shouldn't ask your employees to do anything you are not willing to do yourself. How will you know where to deploy resources if you don't personally learn about them? Involving senior management is critical to any significant organizational change, especially in lean areas.

Lean Principles in Action

The lean team at Meadows developed 44 action items for reducing lead time to admit, treat and discharge a non-critical ED patient, 18 of which were determined to be low cost and high impact. The ideas fell into one of seven categories: 5S/visual controls, cross training, equipment, hospital procedures, patient information, general procedures and staffing. The 5S designation stands for "sort, straighten, shine, systemize and sustain," which is a philosophy and a way of organizing and managing the workspace so morale and efficiency are increased.

Health Management Technology The automated mobile supply stations that make up our Pyxis system, from where we pull supplies based on a patient's name, were all set up differently. Patient service types such as trauma, cardiology, orthopedics, pediatrics and general medicine were used to organize the supplies, which were then placed in specific designated rooms to expedite service and reduce the time spent searching for frequently needed supplies.

Today, the mobile supply stations are all standardized to contain the same general supplies in the same place. Other changes include labeling racks, trays and drawers; installing a color-coded flag system outside of patient rooms; supplying patients with red allergy armbands to alert medical staff; and, adding a holding area for patients who need to see a doctor but don't need a room.

Since the staff performed the analysis, and had been involved in creating the new workflows and organization, buy-in was all but assured. No participants on the staff were left out of the discussions and progress occurred steadily over several weeks. All of these changes have helped physicians and nurses improve their workflow by decreasing duplicated work, time spent searching for supplies and average length of stay per patient.

The T System and Lean

We also implemented the T SystemEV emergency department information system from T-Systems Inc., which was specifically designed for the ED, and which interfaces with other software systems used throughout the hospital. Integrated with the T SystemEV is a large, plasma screen monitor in the nurses' station that can show staff who is in the waiting room, who needs an X-ray and who could be put into a room or a wheelchair. The T SystemEV also is used to document length-of-stays, lab tests ordered, physician and nurse assignments and discharge dispositions, as well as patient names, room numbers and previous ER visits, where applicable.

Previously, the hospital used a pre-cursor known as the "paper T System," which used templates printed out for each type of patient. Of course, as with any paper system, a significant amount of staff time is consumed working with paper charts, moving and searching for them, and completing and filing the documents.

The new system was installed in late 2006 and the initial training occurred over a 3-month period through a team effort that included IS, nursing staff and physicians. The staff — including the physicians — quickly came onboard once they saw how the "paperless" system simplified their work.

In addition, we created incentives for the ED staff to meet our goal of no more than 110 minutes for length of stay. We chose the ambitious 110-minute target as a benchmark that would allow us to beat the national average by half. Timers set to 30-minute increments are activated once patients come in the door, and a team of nurses assist with getting IVs started, providing respiratory assistance or monitoring them with an EKG. Already, the ED staff has met that goal on numerous occasions.

Lean Results

None of these changes involved a long, drawn-out process. Most of the action items were implemented within 90 days, and others were completed within a year. Some actions were as simple as reorganizing a supply closet or rack, or changing the paperwork flow in and out of the department. While those items required only a few hours of meetings to reach decisions, and a day or two to achieve the result, others, such as staggering the staffed shifts of PAs, required weeks of planning and scheduling. Probably the greatest change was the acquisition, installation and training involved with the electronic record.

Health Management Technology Thanks to implementing lean processes, our physicians, on average, are seeing more patients than before, ranging from two to five patients per hour. Of course, productivity varies depending on patient complexity and type, the need for specialty consultation and arrival time.

In 2005, average length-of-stay per patient was 247 minutes. In 2007, it was 139 minutes. That success is reflected in patient satisfaction numbers, which show approximately 92 percent of patients reporting that they are pleased with the quality of care provided at our facility.

In addition to the quantitative measures, there have also been a number of intangible benefits. We now have a group of employees who have learned to view work process from a different perspective. They have started seeing problem solving opportunities whereas before they may not have felt empowered or engaged or had the opportunity to speak up in an area that would make a difference in their daily work. Our employees also feel they are part of business as a result of our open book management policy — a transparency initiative that allows us to share financial information with them.

Lean Moving Forward

Our next steps involve applying lean to the registration process, including online patient registration, self check-in kiosks and bar coding. In addition, when we build a new, state-of-the-art facility, we want to use lean processes before architects even draw up the building. We'll draw a building around the parameters of the number of ED visits, OR visits, square footage needed, beds needed and budget. Our goal is to optimize the process before we draw the first line, so that form follows function.

We realize that the current facility probably represents the greatest challenge to further significant improvements, and while we will continue to implement incremental changes, the relocation to a new facility in approximately two years means that we will likely focus more planning efforts on facility design and new processes related to the new facility over the next 12 months.

In healthcare, we live in these little silos when we should be sharing ideas and resources. CEOs must begin looking for ways to make revolutionary rather than incremental changes. Success in the past does not necessarily ensure success in the future.

Alan Kent is president and CEO of Meadows Regional Medical Center in Vidalia, Ga. Contact him at akent@meadowsregional.org.

• April 2008 FEATURE ARTICLES •

Workflow Management: Case History