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[Music] welcome to another session of inside Washington Hospital today we're going to examine Washington's implementation of the lean management system the healthcare landscape is changing across the country as it becomes more and more difficult to run a highquality health care system and keep cost down by adopting the lean management system we have found a way to accomplish these goals while keeping our Patient First ethic at the Forefront well lean has been around for about a 100 years primarily in the manufacturing industry for the last 15 years it's been used in healthcare with great success lean management is important because when our patients arrive at our door we want to make sure that they have the best patient experience as possible we want to ensure that our patients are able to visit with their Physicians not have to wait a long time and to spend more time with their care provider what is unique about the lean management system is that it actually focuses on two core principles first continuous Improvement and second is respect for people so some of the key terms when we talk about the lean management system actually begin with some of people's favorites because it's one of the Japanese terms that's easy to say and fun to say that's gimba and gimba is where the actual work is done so going to gima means means going to the actual place where we provide patient care when visiting and evaluating the gima it is important for the team members to physically observe the process in order to discover the root causes of delays and defects and to also understand what caner measures may work to solve the problems many times we sit in conference rooms or in our offices and we discuss how patient care is being provided however it's not until you go to the gima when you realize what truly is occurring and so being in the gima allows us to accurately observe how the care is being provided for our patients lean really follows a standard documentation we often call it standard work and really it outlines the steps that you need to be successful sometimes it seems like a lot of paperwork we're writing all the standard work we're trying to time the standard work and really understand the sequence of the steps but really without standards there can be no improvement so once you write standard work then you can improve upon that and so your standard work is the best we have today but then you know you can improve upon that and it's a continuous process and then that leads us into Kaizen so Kaizen obviously another Japanese word but Kaizen is actually two words together so kaen means continuous Improvement but literally translated Kai is to change and Zen is to make better so literally it means to change for the better continuous Improvement has been part of a number of programs that have existed at Washington in the past it isn't just particular to lean and the idea is that as as quickly as you have accomplished a lean process and are beginning to reap the benefits of it you have to go back and look at it again it's kind of like painting the Golden Gate Bridge you start at one end paint the bridge and then it's time to start again our goal in using the lean management system is to focus on the patient perspective and improve processes by eliminating waste or eliminating activities that don't add any value will be better able to make the patient experience the best it can be just as important the system is designed to help streamline workflows eliminate unnecessary steps and generally make things easier for those who do the work when we're focusing on Kaizen improvements and eliminating the waste when of the things that we do as we eliminate is we really are trying to make all of our employees scientists they're actually doing problem solving as they're doing this work you actually look at where are the possibilities for improvement how can we actually decrease the waste from the patients perspective so that it improves their quality and safety visible improvements are hard for the patient to be able to see really what we're aiming for is the feel that our patients have when they come to Washington Hospital we want them to feel that they are really car for we want them to feel that they are not waiting a long time and that they are able to spend more time with their care providers so it's not necessarily they may not notice it from the eye but they should feel it from the way that their care is provided in terms of our Hospital staff and Physicians they are more able to notice the changes because we really focus on making sure that the providers have what they need when they need it and that the process for providing care is more streamlined lean has a concept of waste called muda and it's Japanese for the word waste and they look at things that are built into the healthc care service industry very differently than historically they've been seen before have there are question so we have Trisha Rana and Bill and Central regge so when we're doing Kaizen work improvement work we're trying to understand always first from the patients perspective where is the value added where is the waste that we can eliminate and there's actually seven deadly waste we call them so seven waste that we want to eliminate and they are Transportation inventory motion waiting which is something that patients find very difficult to do and then there's over production overprocess and my least favorite defects the other thing about the that's so compelling about the lean management system is is that it's the people that do the work every day that need to be engaged in the Improvement processes lean management really works because instead of management telling staff what to do we really go to the staff that do the work and ask them to come up with the ideas for improvement in this methodology it's actually the people who are doing the work daytoday that get to say this is how I want to improve the process and when you see people involved in that whole searching for Solutions it's really exciting to see the light bulb go off when they say yeah this is how I think it should be done and it's possible that's what we're going to do I like the lean management system itself because you're able to test ideas and know whether they work or not and you can adjust them second one is Dr sxa said she does not get result right away so she sends to NorCal when we do Workshop it only takes about a week to test those ideas and you can see result by the end of the week it works because the people that are doing the work the clinicians the leadership the staff begin to understand that it really is changing their patient satisfaction it's changing the work that they do and they begin to change their behaviors which then changes the culture and then you see it actually working when you sit down to go through a lean exercise the people people in the room have all parked their official titles at the door and you have a mix of Physicians from the medical staff management executive staff hourly employees all sitting together working on a common problem and developing a common understanding of what that problem is and then coming up with Solutions together it is a process of fundamentally altering how people do business in the hospital scheduled for after the needle when we come back we'll illustrate just how the lean management system works and take a look at some potential improvements and some we've already [Music] made actual practice of the lean management system begins with the creation of a value stream map or vssm or a specific area or process value stream mapping is the process of following a patient through their care here at Washington Hospital whether they're having a service provided or procedure our team of Physicians and staff follow the patient to make sure that we're able to document the steps it takes to provide the care lean gives us a great melding of both uh methodology and tools that help us really identify what waste is one of the jobs of the Kaizen teams is to go out to the workplace and look at what's happening in the work workplace that might be considered waste and when we go out to the workplace we really try and have big eyes big ears we don't talk we just observe and we watch how people do their jobs and look at the ways that we think they could be doing their jobs more efficiently write them down on a little Post-it notes and then use the lean methodology to characterize those wastes once we have the steps documented we create what's called a current state map a current state map really is all of the process steps it takes to provide the care we then look at the current state map with the goal of trying to find ways that we can improve the process and reduce weight times once we have a current state map we then develop what's called a future state vision the future state vision really looks at what can we do in 3 to 5 years how can we improve the process and once we have our future state vision we develop what's called an implementation plan and the implementation plan is our way to make it to that future state map and we really focus on the first 12 to 18 months and what we can do right away to improve our patients care let's look at some specific ways a lean management system is already improving value eliminating waste and benefiting you the patient here at Washington Hospital my name is Michael pler I'm the ER manager and I was one of the first executive cohorts to take the lean training we did a analysis of one of the bedside nurses and basically the nurses were walking back and forth for each patient to get to get supplies they needed routine supplies so they were wasting a lot of steps and you can tell how many steps I'm taking here if you multiply that by you know 20 patients a day um that's a lot of steps yeah yeah so as an offshoot of that we decided to deploy the bedside carts at each room so the most commonly used supplies would be readily available for the nurse and he or she would not have to walk as far be more efficient and provide more FaceTime with the patients it was 6,000 steps in 4 hours for the nurse assigned to this area rooms 5 through 8 and uh dropped it by half we purchased these bedside carts put one in each room and selected what items they Ed the most were used most frequently and then we looked at the inventory that um Oscar maintains downstairs you know and we came up with what needs to be here they developed what they wanted with some spatial constraints they developed the stuff they used most frequently on top and the stuff they use least frequently on the bottom again are a few things on the bottom these frequently but by size they can't fit on the top and then we had to the EMT was pivotal and uh designing this because we labeled each one of them we have the clear plastic dividers here so that you can instantaneously without counting the inventory instead of you know going through 1 2 3 4 5 6 you can just look at how it's supposed to be filled to the top it allows the nurses to spend the most more time maximize their time with the patient which is what the patients really here for they're here for uh um Direct Care they're not here for nurses running around um again grabbing supplies and this allows the nurses to be more efficient which utilizes their time better and it's is also better for inventory control um it's a visual signal for the the MTS to restock so they don't have to count and take their time as well is that why it's going back up no it's that's why I place that drain so she has so the no delay huddle came about because we were trying to get the nurses the handoff of the nurses the vital patient information historically it's been a verbal handoff two nurses on the phone talking and because of the different uh requirements they have on the floor and things they need to do sometimes that wasn't possible in a time efficient manner the Ed nurse was busy when the floor nurse was ready for report the floor nurse was busy when the Ed nurse was ready for report sometimes that occurred a delay of 30 minutes which is no value added time for the patient's perspective they retooled the Handover tool within so the process is such that the bed control person assigns the bed with the Chargers on the floor then tells the nurse they should expect a patient that nurse goes on to and looks at the various um information that's available for the handoff if they have any questions they call the Ed staff the Ed staff at this point gives a courtesy call when the patient's coming up and explains any other information Vital Information that's not contained in the report that the floor nurse uh feels they need to have the modular building is obviously outside of the main Ed space but it is where we do our triage and waiting room functionality historically we did uh the nurses manned that area however the nurses were triaging the patients at the same time and sometimes it became difficult for them to keep up with the patients coming visitors coming good morning how can I help you you need to see the doctor this morning yeah I have a searing pan in my arm I think I might have broken it okay I need you to fill out this form for us this morning have you been here before no so as part of our uh rival registration Workshop we designated a registration clerk to man the window and that registration clerk greets every patient and that way the patients don't wait patients are seen appropriately and they arrive the patients in the computer which uh assured the accuracy of the patient information in the computer okay T why don't you come on in it also allowed the nurses to manage uh the triage better and the flow of patients better through triage because they weren't interrupted doing clerical activities and our satisfaction um has steadily increased since the implementation of that um Workshop we'll be back after the break to examine how the implementation of the lean management system effects the residents of our district and supports our Patient First [Music] ethic the advantages of increasing value and reducing waste at washing Hospital results in benefits beyond the specific departments and individual activities the effects of these changes are felt not only by our patients but by the residents of the district as well lean is a system that really works well to improve patient care and I think it does it both from an individual standpoint and a institutional standpoint so from an individual standpoint as patients we all want an experience where we're not waiting our time isn't wasted where most of our time is spent with our clinical providers rather than waiting for them to look at the computer or go find something that they don't have so lean is really A system that optimizes those processes so that we get that that patient experience from an Institutional standpoint it's really about optimizing our systems so that our processes help us provide the highest standard of care it's really about defining what is the standard and having every Everybody work to that standard lean management is racing and developing people it is believing and trusting the people who do the work know what the problems are and given the right support they will make that valuable improvements many times when you're implementing a new project or process it takes many months and sometimes years to actually come to fruition with lean management we're able to see change within 5 days and so it's really excited to be part of the change to improve the process for our patients we really value our patients we have a patient first ethic here at Washington Hospital and it's great to be able to provide such a wonderful service for our patients and to constantly be improving it right we'll use your on here okay any we can travel outside of the country I think the most overarching value of lean has been the focus on the patient experience and providing the most quality patient- centered care that we can and the most efficient mechanism possible increasing patient Satisfaction by decreasing Ed weight times from our perspective and providing care in in an economic responsible fashion to the district residents from my vantage point I think the lean management system has been a positive Endeavor it's a cohesive and a collaborative endeavor and it's brought a lot of Divisions in groups together to work on a common goal and that's to provide the best patient care possible the thing that really excites me about lean is that I feel that it is a comprehensive approach to Quality Care there are lots of quality uh initiatives that have happened uh across healthc care in many different areas but I think lean really brings that together and it's one approach that not only touches efficiency but really builds quality into our processes and that to me is really exciting the last thing about lean that I think is really important for providing highquality patient care is that it's really a model for continuous Improvement so lean is not just about going into one area correcting that and then you're done and moving on to the next area it's really about keeping focused on an area thinking about continuous improvement keep thinking about okay you have a great process but how do you take that and improve it even more and so it's really a lifelong journey for the hospital well lean management uh system is a good fit to Washington Hospital because our focus is always the patients and we do this continuous Improvement to aim for that uh Perfection to continuously improve our processes with the Advent of the Affordable Care Act the amount of money coming into the Health Care system was clearly going to change radically it was very clear to me strategically that the hospital needed to become the highest quality lowest cost provider of Hospital services in order to survive in the New World Order you're okay to walk back to see the doctor uh yeah okay why don't you go ahead and follow me we'll get you back okay well the hospital is a public trust and I believe that we are Duty bound to operate it in the most efficient and coste effective way we can yet still providing all of the services that they need and lean is a vehicle for getting to that place and so I think that it is very consistent with the concept of a public trust and being accountable as you've seen the lean management system gives us an excellent opportunity to make a positive difference to Washington Hospital right away and also longterm term and the gains made will be felt by everyone at Washington Hospital by the patients and their families and by the community we support thanks for watching I'll see you next time on inside Washington Hospital [Music] [Music] [Music]