Lean Management: Dropping D2B Times and Eliminating System Waste

Can you tell us about your cath labs and the community that you serve? I supervise both cath labs at Appleton and Theda Clark Medical Centers. Appleton Medical Center, where we do the majority of our cardiac procedures, has two interventional cardiac suites, an angio suite that does interventional radiography as well as some cardiac procedures, and a dedicated electrophysiology (EP)/ablation/pacemaker suite. At Theda Clark, we have two labs, one interventional cardiac cath lab and a biplane neuro-interventional radiography lab, where we do coil neuro-embolizations, angiograms, peripheral stents, etc. The two communities served by these hospitals are approximately 14 miles apart. The overall area, called the Fox River Valley, is probably close to 300,000 in population. When did the hospitals first begin using lean management techniques? With a focused commitment on improvement, ThedaCare, our parent company, started on the lean journey six years ago to relieve overburdened employees, improve patient care, and save dollars on the bottom line by applying a hospital-wide strategy that seeks improvement across the network. The hospitals started this process with ST-elevation myocardial infarction (STEMI) back in 2006. At that time, the national standard for door-to-balloon (D2B) time from the American College of Cardiology/American Heart Association was 120 minutes. We thought we could do better and went through a rapid improvement process, part of using lean management, which is modeled after the Toyota production system. Our goal was to get our D2B times down to less than 90 minutes, even with the 120-minute standard in place at that time. Before we did the rapid improvement event (RIE, a one-week focused effort that is highly facilitated and concentrates a dedicated team on getting results immediately), we were only reaching the 90-minute metric 58% of the time. After we did the RIE, the system was streamlined so we could achieve a D2B time of less than 90 minutes 100% of the time. In 2007 and 2008, we went further, setting a metric for our in-house D2B STEMIs of 60 minutes. We were able to achieve that solely through our process improvement. After the RIE, the interventionalists, ER physicians, ED nurses, cath lab nurses and cath lab techs all had developed standard work to follow at Appleton Medical Center and Theda Clark Medical Center. The standard work kept everyone on the same page of the process. How did your healthcare system settle on lean management as a way to improve? Our previous CEO, Dr. John Toussaint, visited a local manufacturer, Ariens, in Brillion, Wisconsin, and was exposed to lean management. Dr. Toussaint then contacted a lean management consulting company, Simpler Healthcare, a division of Simpler Consulting, to discuss lean in healthcare. Dr. Toussaint felt that the lean principles worked so well at taking the waste out of manufacturing that it would be an ideal fit for healthcare as well. In healthcare, our costs are going up and our reimbursements are going down. Healthcare is riddled with waste and inefficiency. Our patients expect quality and value, and as healthcare workers, we need to deliver that at a lower cost. Using the lean tools, Dr. Toussaint gradually changed the culture of our organization so that everyone got in tune with removing waste. Lean is all about removing what the Japanese call ‘muda,’ or waste. We mapped all of our processes, making an effort to remove as many non-value-added processes as possible, although some cannot be eliminated, like registering patients. Anything where you are waiting is waste. A general example of non-value-added is standing in line at the airport. You finally get up to the ticket counter and the agent asks you questions and checks your bags — that’s more waste. The only value added is getting the ticket and getting on the plane — out of how many steps? We used the same analogy for healthcare. There are processes we mapped out where we might have 40 or 50 steps. If we could cut those steps in half to perform the same process, and build it into our standard work, it would be easier on our staff and more efficient for us, allowing us to spend more time with our patients. Lean is a cultural change that must take place throughout the whole organization, and it doesn’t happen overnight. It is a culture that takes years to implement. What other changes did your cath labs undergo? We also had a RIE on supplies. We went through all of our supplies and found we had $78,000 in expired product or waste. Our supply turns were at 5. We weren’t turning over our stock fast enough. We said, let’s shoot for 12 turns as our metric. In actuality, it ended up being 9.5 turns. What this meant was we had more just-in-time (JIT) supplies, but we also ended up putting more product on consignment. In addition, we implemented several visual cues where the stock was located and determined par levels for each location, so we wouldn’t overstock and have to throw out $78,000 worth of supplies at the end of the year again! It turned out that we had so much excess stock that we were able to return a great share of it for a one-time $155,000 savings. We have used the process of lean management for everything from how to handle inventory to how we do our STEMIs, to our case turnover. Our case turnovers decreased from 20 minutes down to 15 minutes. Visitors have come from other hospitals to see how we do it, measuring our times with a stopwatch. From “toes out” of one patient to where the cardiologist is ready to access the groin on the next patient, timing is down to 15 minutes. These types of improvements are done by getting staff involved. This starts from process improvement and the staff putting together the standard work in that process. Part of the lean culture is that change comes from the bottom up, unlike Six Sigma, where it comes from the top down. Lean is a very participatory style of management. We give the staff direction and say, here is our goal. Then we all sit down and map our process during a RIE to find the best way to reach that goal. The nurses and the techs all designed their own standard work and had a consensus on the final draft. Standard work is not meant to be used as a club. Standard work is a living, breathing document. Sometimes it changes. As our business model changes, standard work changes with it, and that goes back to the staff. If a step or task is considered non-value-added and everyone agrees, we won’t do it anymore. It all comes down to engaging the staff and engaging your physicians. Actually, anyone who ever touches the process needs to be engaged. In the beginning, the Simpler Healthcare consultants told us: You are changing someone’s life. You are changing how they do the work. They are the ones that understand their work and you had better get them involved. The example they gave us was one of sitting down next to your neighbor, taking their wallet or purse, completely rearranging it to the way you want it, and then returning it to them. Think they are going to be happy? We are hiring highly educated and skilled people. We want them to use their heads. We want them engaged, we want them to buy into the process and we want it to become part of their culture. The only way to do it is to have them participate. What were some of the challenges you faced when you began looking at changing your D2B times? At one time, the cardiologists were the only ones to call a STEMI. They would have the in-house on-call cardiologist call it, then contact the interventional cardiologist, who in turn would talk with the ER doctor, and then the interventional cardiologist would come in and perform the acute case. It added a lot of excess time. The cardiologist and the ER doctors agreed on a model where the ER doctors would call the STEMI, and then a page would go out to the cath lab crew and the interventionalist to immediately come to the hospital. The cardiologist, as part of the standard work, would call the ER doctor immediately to let them know he’s on his way. The biggest change was having the ER doctor be the gatekeeper to call the STEMI. In the beginning, a 5% normal rate was expected and we had that rate. Crucial to the process was getting the trust between the ER doctor and the cardiologists; it was quickly developed and ended up working out fine. Most of the cardiac procedures are done at Appleton Medical Center, which has a 20-minute call-in time. At Theda Clark hospital, they don’t do as many acute MI cases. They’ve been at 30 minutes for years, and it was a matter of leaving them at 30 minutes like the rest of the country, or losing staff. Who do you have transport the patient from the ER to the cath lab? As part of their standard work, as soon as the cath lab RN comes in on call, they go immediately to the ER. The ER has a protocol. In each of the ER rooms, the same standard work is displayed on the wall as to how they should handle the STEMI patient: EKG, what drugs to give, and so on. The cath lab RN will take the patient immediately up to the cath lab, along with one or two nurses from the ER. In the cath lab, the scrub tech and the CVT already have the case set up, the x-ray equipment turned on and tested, and they are ready to roll. ER staff always helps transport the patient to the cath lab. The cath lab isn’t going to delay bringing that patient up, if, say, the groin isn’t shaved, or if a certain medication isn’t given. They will handle it in the cath lab if need be. As soon as the case is done, we call down to the ER with our balloon time. The ER tracks the D2B time on the tracking board in the main hallway within their department. As soon as the person comes through the door with chest pain, the ER hits the registration button and there is a time on the EMR. The ER also tracks the door-to-EKG time, because we want to see where our lags are. Early on, we also tracked our ED-to-cath lab door time and cath lab door-to-lidocaine time. We wanted to find out where opportunities were to reduce our times. Occasionally, we do have times that have been outside the boundaries, so we take a look at the data and ask why. Part of lean is to ask the “5 Whys” (a question-asking method used to explore cause/effect relationships) to drill down on the problem. Sometimes the STEMI doesn’t show up on the first or second EKG. Sometimes it might not show up until the patient is in the ER for an hour. You still have to go back to the door time, so that will give you an outlier on your D2B times. Over the last year and a half, we have expanded our STEMI processes to seven other hospitals with Remote Code STEMI, as well as two field ambulance services. We took a system that worked and added one hospital at a time, refining what was at Appleton and Theda Clark Medical Centers. Two of the remote hospitals were in the Thedacare hospital systems and the other hospitals refer their patients to ThedaCare. The person responsible for spreading the process was our remote STEMI coordinator. Just as we had a RIE at Appleton Medical Center, the remote hospital would also have an event to get all the players involved and spread the work. Our metric for our remote STEMIs is 90 minutes or less. The first mode of transport is going to be helicopter, unless the weather is bad. Then they have to send the patient by ground. Once it is decided that a patient needs to be transferred to Appleton Medical Center, for example, the referring hospital will call the ThedaStar dispatch, our chopper service, to say they have a remote STEMI. The system is then activated. The interventional cardiologist on call is sent a remote STEMI page and will come into the hospital. There is a 3-person cath lab call team: two techs and an RN. The RN from the cath lab will meet the chopper crew in the ambulance garage, so the patient doesn’t stop in our ER at all. ALL remote STEMIs come directly to the cath lab. What are some of the challenges you are currently facing? Our remote STEMI coordinator has left. We need to hire a new STEMI coordinator because we want that one common denominator — one go-to person for the whole organization, as well as our 7 hospitals and 2 field sites. We would like to spread our STEMI program further, but we are holding off right now until the new coordinator is in place. Some of my other challenges are reducing our expenses and controlling costs, much like the rest of the cath labs around the country. We are always negotiating with vendors, working to find the best deals, sign contracts, whatever we need to do to get best pricing, because when you are dealing with Medicare and Medicaid patients, your reimbursements are going to be lower. We still need to provide high-quality service and we need be cognizant of our spending. I try to keep as many consigned supplies in the cath lab as possible. It is important to ask the physicians and get them involved in supply decisions. They are also concerned about cost. So getting our physicians involved is key. As we are going towards more pay-for-performance and quality metrics, I can’t emphasize enough that we need to be one with our physicians that are working in the cath lab. We have to come at this as one united team. Physicians are data-driven. They are scientists. If you want their buy-in, you are going to need to provide them with data. Our physicians continue to be very involved in our STEMI data and turnaround times. At Appleton Medical Center, for the last four or five years, we’ve been doing cardiac interventions as an outpatient procedure. Patients come in the morning to the cath lab special procedure outpatient area, get prepped, come to the cath lab, have their procedure, and shortly thereafter, within 5 hours, they are home. Part of what has allowed us to do that is closure devices. Even though we are not reimbursed for closure devices, it does save hospital time and allows us to send patients home without any groin complications. Also, the use of bivalirudin has helped. When bivalirudin is shut off, it’s off. We don’t have as many concerns about these patients bleeding from the groin site. What do you see as the future for your organization? We are going to do more and more outpatient work. Our reimbursement is going down. So if people aren’t efficient in their processes and reducing costs, they need to start. If our hospitals are going to survive, we are going to need to continue using lean management tools. There is too much waste throughout the healthcare system. Mike Rodman can be contacted at (800) 236-4101.

NULL