LEAN lessons from auto industry driving major improvements

Turns outs an auto manufacturer has a thing or two to teach Canada’s largest teaching hospital.

That’s why Toronto’s (UHN) is taking a lesson from Toyota and designing patient care using a system.

The approach provides employees with a systematic method for continuously improving the way an organization runs, by first standardizing processes and then making small, incremental changes in order to reach important goals. Decisions are based on data, and both errors and waste are reduced by making processes easy for staff to follow correctly.

When a problem occurs, the root cause is identified before a solution is implemented.

“Toyota has one of the most advanced process improvement cultures in the world,” says Brenda Kenefick, Director, Process Improvement, UHN. “While people often tell me that treating sick people is very different from manufacturing cars, we can learn a lot from Toyota about how to create a culture where we achieve specific goals by teaching every single staff member how to identify problems, and develop effective solutions.”

Such improvements are necessary for healthcare organizations to be able to meet the demands of an aging population while increasing the quality of care without substantial additional funding.

The following examples from UHN show what can be achieved with a continuous improvement culture – safety improves, wait times shrink and patients go home sooner.

Improving safety

It was a moment three-and-a-half years in the making.

The team on a spinal unit at Toronto Western Hospital (TWH) recently celebrated 60 days without a single patient developing a pressure ulcer. It’s a first for the team, and for UHN.

And it’s particularly impressive given the limited mobility of the spinal injury patients the unit treats.

Pressure ulcers occur when the skin breaks down due to prolonged immobility. They are painful and notoriously difficult to heal once they develop. They are also preventable.

“We work very hard to be preventative and proactive,” Rosemary Ritchie, the former nurse manager, now retired, says in explaining how her team reached this milestone. “We discuss every patient that comes on to our unit during our daily huddles.

“If they are deemed at risk of developing a pressure ulcer, a fall or a urinary tract infection, we flag them on our risk board and act immediately by involving other team members or employing the necessary equipment to prevent harm.”

The team also realized that to prevent pressure ulcers they needed to better educate patients and families on what happens if they don’t turn, or move. Patients can be totally dependent on others for their movement, and may not always want to mobilize. Educating them on why it is important to roll over or move to a chair helps the team blend their comfort and safety.

Reducing wait times

Some patients at Toronto Rehab are now getting in the door much earlier. And when it comes to rehabilitation, how soon a patient starts may affect their recovery.

You might think reducing wait times comes at a cost – more infrastructure, more staff, more hours. But it turns out the best way to solve big, complex problems like wait times is to work with the people doing the job to solve the small, simple problems.

By doing that, the Stroke Outpatient Rehab Clinic reduced its wait time from 15 days to six.

Clinic patients need to see up to three clinicians in one day, three days a week, for at least four weeks. It’s a scheduling challenge that the team used to manage by meeting once a week to find a way to fit in all their new patients.

By finding a new way to schedule the team can now come up with appointments as soon as the referral is received.

“You have to be adaptable,” says Georgeta Savu, manager, Stroke Rehab Outpatient Rehab Clinic, Toronto Rehab. “In order to make any changes work, you’ve got to be prepared to measure them, evaluate and make changes when necessary.

“Most importantly the team knows their goal, and came up with the solutions themselves. It’s a significant change and one that was achieved by the team.”

Streamlining discharge

The longer a patient spends in a hospital, the more time they spend at risk of a fall, a medication incident or acquiring an infection.

That’s why hospitals need to discharge people as soon as they are ready to go – getting them to the right place at the right time.

One unit at the Peter Munk Cardiac Centre (PMCC) has done just that.

“We’re not doing this to create more bed space,” says Jeanne Elgie-Watson, nurse manager, PMCC. “In our effort to become a high-reliability organization, we need to look at reducing length of stay as a fundamental part of improving patient safety.”

Patients on her cardiovascular surgery unit are heading home with or without support, on average, just over a full day earlier than they were three months prior.

That’s a 16 per cent reduction in length of stay, down to 6.1 days from 7.3 in just 12 weeks.

“We achieved that by smoothing out the barriers to timely discharge,” says Jeanne. “The work started with help from the Lean Process Improvement team in our Rapid Improvement Event and it’s continued every day since in our huddles.”

While the team made numerous minor changes to the discharge process, much of the improvement stems from three major changes:

  • Ensuring test results are ready in time to discharge the patient.
  • Continuous communication of an up-to-date discharge plan to the patient and their family.
  • Daily huddles implemented by the clinical team to discuss process problems and discharge rounds so as to identify patients who will be ready for discharge within 48 hours.

“The medical team usually needs the results from morning blood tests and echocardiograms before discharging anyone,” says Jeanne. “The night shift now draws blood by 6 a.m. for patients we’re planning to discharge that day.

“By starting the process earlier, we get results back in time to make decisions.”

After surgery most patients need family support to safely transition back home. The team communicates the estimated discharge date to the family two days in advance, giving them some time to make arrangements for transportation and home care.

The engine driving these improvements has two components. The first part is the team’s daily huddle where they address process problems, and the second part is their new discharge rounds. At 1:30 p.m. every day, the entire team gathers for 15 minutes to identify any patients who will be ready for discharge in the next 48 hours and discuss their individual needs or outstanding tests.

The unit’s target length of stay is six days. When they beat it, they celebrate as a team. When they meet it, they record it as a success on their performance board. When a patient is discharged on day seven or later, they find out why.

Often a delayed discharge is because the patient required more medical care. If the delay was due to a problem with the discharge process the team is reluctant to simplify; they dig into the root cause and address it.

“Everyone knows our goal, and we work together to achieve it,” says Helen Zhang, a Nurse Practitioner at PMCC. “Whenever a patient is ready to go home by day six after surgery, we cheer.”