How to Run a Lean Event at your Hospital

Inefficiencies can lead to mistakes, wasted time, and frustrated individuals, which can result in deadly outcomes or long lengths of stay. One solution is to run a Rapid Improvement Event (RIE), a five-day workshop that brings together a multidisciplinary team to develop methods of cutting waste from workflows such as patient discharge, ED triaging, or patient transfers.

Understanding the Differences Between Lean and Six Sigma

Understanding these differences can help you decide what’s best for your hospital. Lean focuses on cutting waste by approaching workflow and throughput visually, using diagrams, charts, and lists, ultimately aiming to reduce non-value added time. Six sigma also promotes efficiency, but does so through eliminating variability. Rather than visual representations, six sigma achieves its goals by tackling the underlying, or root, problems with mathematical and statistical analysis.

DOWN TIME looks at the eight wastes in healthcare. As you think about your hospital’s daily routine, you may realize there are more wastes than expected.

Defining Your Rapid Improvement Event (RIE)

Operating under the motto “rapid change, precise planning,” a RIE is an engine of change developed by hospital leadership. Also known as Kaizen Events, the workshop itself only lasts five days, but to be effective, requires thorough preparation and follow-up.

Important roles to define during your planning stage include:

However, while these changes are spurred by specific roles, feedback from all impacted groups is crucial.

Leading your RIE

A five day workshop may seem intimidating to lead, but with the right tools and clear communication, your RIE can run smoothly.

A3 Thinking

At the core of a RIE is A3 thinking, a lean process methodology that helps visualize how your team can move from “current state” to your ideal “future state.” Begin with folding a piece of paper into nine squares. Boxes 1–3 look at current problems in order to guide you to your target state, and should be completed by leadership during the planning stage. Boxes 4–6 guide your team through the experiments and analysis, while boxes 7–9 focus on post-event. Metrics used to track changes can be developed and agreed upon and a completion plan is formed at the end of the RIE.

Day 1: Current State Understanding

To kick off your RIE, review your A3 boxes with all participating members. Once the target state and metrics are aligned, it’s time to take the team on a “gemba walk.” A gemba walk encourages each position to think about areas of waste by physically walking in another individual’s shoes to understand his or her day. Remind team members to not think of waste in a judgmental manner, but rather as areas of general improvements.

As you begin to form your current state map, use visuals to see inefficiencies more clearly. To understand physical movement, use a spaghetti diagram to map out the walking paths of different roles each day. For example, teams track how many times a doctor walks from his or her office to a patient, or pinpoint frequently visited spots. A communication diagram follows the flow of electronic, verbal, and written communication between doctors, case managers, nurses, etc., in addition to the patient’s family members, PCPs, and others.

Time studies is a tool that looks at touch and flow time. Touch time is the amount of “hands on” time is spent completing processes such as patient transport, note taking, recording vitals, etc. By paying attention to exactly how much time each action takes (including interruptions and lag), we can fully understand flow time, or the total time it takes to complete a process.

Day 2: Target State

A critical component to day 2 is getting to the core of inefficiencies, while thinking outside of the box. Have small teams build target state maps independently of the other teams; rather than skipping ahead to possible solutions, focus on locating everyday pain points.

Gap analysis hones in on the root cause of a problem, or what initiates a chain that leads to the undesired outcome. If you already have an existing solution to a problem, ask yourself again if that’s the solution to the root problem using the “5 Whys”.

After identifying the root of the problem, it’s time to take a solutions approach. Using the “if, then” approach, we can hypothesize the outcomes to rapid experiments. For example, if communication delay causes late discharge times, then leveraging technology tools can help reduce these delays. Now, these hypothetical solutions can be tested and quantified by running rapid experiments. Experiments should consist of four sections: what is the experiment, who is involved in preparation and execution, expected result, and actual result.

Day 3: Experimentation

Now, experimentation should be in full swing. From rework to brand new ideas, remind teams not to feel discouraged if their solutions aren’t working. If you have found the root cause of the problem, the solution should prevent that from recurring.

Day 4: Standardization

A strong standardized process can fully and accurately inform individuals who were not part of the workshop, such as other existing and new staff members. At the end of the day, standard work is a living document, and updates are needed as further improvements are made.

Adhering to lean methodology, adopting a process control board (PCB) or daily management system will help track daily metrics post-event. It’s important to ensure that a completion plan is in place — a good place to start is documenting improvements made to baseline metrics. For example, two major items to keep metrics on include “staff trained on standard work” and “staff knows how to use the daily management system.”

Day 5: Communication

Day 5 focuses on the communication plan so leadership, RIE team members, and all have access to the A3 chart. Senior leaders and POs should be walking the new process everyday for at least three weeks in order to problem solve daily. In addition, the VSST should be reviewing A3 and key metrics every month.

Best Practices

Remember that the goal is to provide the effective care for patients, and that can be achieved through transformational learning and standardized practices. This framework allows teams to quickly identify and eliminate inefficiencies in critical workflows that may impact key measures such as length of stay. While these lean principles may take time to adopt, its benefits can be countless.