zondag 1 mei 2011

Lean in health care: changes on the Gemba
Gemba: where the work is actually being carried out

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In the following story, a number of practical lean tools are being used. But in such a way that even those with less lean insights can understand this post. Addressed are problem solving (A3 thinking), the work breakdown sheet, waste and countermeasures. But it is primarily a story about how these tools have contributed to a thoughtprocess of change. About breaking resistance to change. And how management, through the proper application of tools, has gained profound understanding of the work being done by health professionals.

Change hurts 
We had a simple target set out by our department chair: you have to do the same work with fewer people. A simple task but one that led to a lot of commotion. "You can not compare us with just any other treatment center" or "let the doctors get their act together first." But we were going to give it a go anyway. Through commonly known methods: a project team was formed, made an extensive project plan and went to work. That work consisted mainly of many complex discussions. About why. About the how. Long meetings in which we agreed on how to defend why results had not been met. And what new solutions were suggested. Which brought on a lot of new work for another couple of weeks. But despite all the creativity, intelligent and even professorial efforts we seemed unable to get a breakthrough in our way thinking and doing.

What is a problem? A problem is the gap between current and desired situation. So in our case: the current situation is a process with four employees per linear accelerator (irradiation apparatus). And the desired situation is one with three employees. How do you get fundamental understanding of the current process? In any case, not in conference rooms to speculate about that process. But by actually going to the the spot where the work is being done, to look and to talk to the people who run your daily business!  

 We made a video of the process of treating a patient with every action of every employee, captured. And made it into a kind of process picture: an analysis using a Work Breakdown Sheet. What were the lessons learned from that 'picture'? First, the existence of overburden ("muri" in Japanese): the patient treatment was set at 8 minutes. But each treatment took about half a minute to one minute longer than that. And thus proving we asked of our health care providers to work under constant pressure! But also that there was more than 50% of waiting time in the process, one of the known spills by lean practitioners called "Muda". Waiting by the worker who operates the machine while his colleagues support and install the patient. And conversely, waiting by the colleagues who just supported the patient while the actual operation takes place.

Gap (2)
But how to close the gap? Soon we arrived at the idea of ​​doing a simulation: a simulation where one of our staff played out the role of the patient and where we would operate with fewer people and within eight minutes off treatment time. What this might look like was set up in a sheet just like the earlier breakdownsheet. During that simulation we were very soon made aware that it was an almost impossible task. Things were not in the right place, distances to materials needed proved too great, information was not available at the time it was needed.

A very practical example: the paperholder with the paper for the treatment table was about 2.5 meters from the table to the wall. For each patient a new paper was needed and a distance of  5 meters needed to be walked. Not a big problem. Until you have to walk that distance for 55 patients per day. A very simple and convenient solution then, is to replace your paper holder on to the treatment tables themselves.

It was not only unfeasible, it would, had we persevered, even have become an extremely uncomfortable experience for both patients and staff. And the motto that we started our lean journey out on was "Lean, compassionate and a great-place-to-work". Persevering would have had nothing tot do with that motto.

Continuous improvement 
During the simulation, besides the example of the paper on the treatment table, at least 25 improvements were identified that may contribute to a treatment that adheres to the desired situation with fewer workers. Improvements that don't çost' in terms of of compassion, time, attention and patient satisfaction. Those improvements are now being implemented one by one. Which ones will make the greatest contribution we do not know as of yet. But every day brings us a little bit closer to the goal. And there are now even some of our lineair accelaerators where we have reached the desired situation of working with three workers! Where the target as set by the department chair, has been achieved. Where we work lean (or: smart) with fewer people, whilst not working any harder. And where patients are at least as satisfied as they were before.

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