Lean management at Jasmine Hospital
Lean Management in Healthcare
Lean is a set of methods and philosophies of operations that help in the creation of maximum value for patients through the reduction of waits and waste (JBA, 2014). The aim of lean strategies is to alter the way organizations think as well as what they value, which eventually results in organizational change in its culture and behavior over time. It is based on the Toyota model and focuses on the efficient use of resources and zeros in on what value is added to the clients at every process stage. The healthcare industry has adopted a lean process in countries such as the US, UK, Canada, and Australia (Smith et al., 2012). Lean processes in healthcare utilize a learning cycle that is continuous and one that is driven by process experts being the healthcare providers, patients/families, and support (Campbell, 2009). This paper will analyze a case study where a lean process application can be implemented to improve efficiency in a small community served by the Jasmine Hospital in Pine City, Colorado.
The Initial Problem
The main problem is the recurring accidents that can be minimized or completely eliminated with the right strategies in place. The county has a low population of only 80,000. Reaching this number of people and having a talk or open forum that discusses why accidents occur and how they can be prevented including the role each person can play in reducing them should not be an uphill task. With a reduced number of patient hospitalizations from head trauma, can and should significantly improve the efficiency of Jasmine Hospital, including costs of care. The hospital would then have the capacity to care for other patient needs that are perhaps unpreventable (Furterer, 2018). The population comprises the elderly and the ‘fertile’ groups. When accident victims are reduced, the hospital can cater to the elderly population, the ‘fertile’ groups health needs to maintain a healthier community.
The Stakeholders and Their Needs
The first customers in this community are the children. The population has grown over the last ten years, and since they are in the 25-50 years age group, it is expected that most are young families with children. The second group of customers is mothers and mothers-to-be. This group needs a pre and postnatal unit that cares for them and their babies/children. The third and fourth groups are the teenagers who would fall into two categories of stakeholders; the first being teens (and young adults) who seek reproductive health services (contraceptives) and teens who come to the hospital because of neuro-ortho needs following accidents. The fifth group is the elderly in the community who report to the healthcare facility with geriatric-related health complications
How Each Customer Would Describe Satisfaction
The young children would be satisfied with the healthcare services when their growth and health are monitored through regular check-ups to ensure they are within the right growth projectile. The mothers and mothers-to-be would be satisfied with the safe delivery of their babies, including their own safety during and after childbirth. The teens/young adults would be satisfied when their reproductive needs are met and proven to be effective in controlling unwanted pregnancies, their privacy is maintained, and in controlling the spread of STIs/STDs. Teens would also be satisfied if and when following trauma, the surgical operations are successful in extending their life spans. Lastly, the elderly will record satisfaction when their quality of life is improved through better management of their geriatric-related illnesses.
Current Process at the Hospital
When patients check in to the hospital, they need to register with the clerk at the reception. This involves filling out a form that requires not less than 20 fields to be entered. The patient then waits for approximately 15-20 minutes before going in to have their vitals checked by the triage nurses. The nurses take details from the patient on their symptoms but only record the patient’s vitals information in the EPR system. The nurse also forwards the name and details of the patient to the next available doctor. The patient then has to wait until his/her name is called out to see the particular assigned doctor. The patient will often take 20-30 minutes at the doctor’s room after which his/her name is forwarded to the pharmacy where he/she is expected to go and wait as their prescription is put together. If the patient does not have medical insurance coverage, he/she should first go to the cashier and pay for the drugs before coming back to the pharmacy and picking up the drugs after presenting the receipt as proof of payment.
For patients who are in need of surgical procedures, they are first observed and scheduled by the physician for specific times and dates. If for example, a patient needs a hip replacement done, the physician will carry out a medical examination and schedule the procedure for a specific day and time. The patient will remain in the healthcare facility for a duration of time after the surgical procedure before being discharged and scheduled for check-up appointments until full or reasonable recovery is achieved. However, this process of scheduling surgical procedures is often disrupted by neuro-ortho cases that comprise head traumas and compound fractures. The ORs are ever busy, and patients with non-emergency procedures are forced to wait as their treatment is rescheduled to cater to the more critical emergency cases. Additionally, because doctors have to come from the specialist center that is two miles away, it takes time to get the surgical team ready and work on a patient in a seamless manner. The waiting time takes 2-4 hours, not to mention the time it takes to get the patient prepared for the surgical procedures. This often results in death due to delays in addressing the critical patient’s needs.
Identified Wastes in the Process
The number one waste in the hospital procedure is Time. For everyday ED patients, the registration process takes very long. This is especially so when a patient does not speak or understand English; getting accurate information from such a patient is close to impossible. The redundancy in service provision is also another weak point. The patient gives the nurse details of their symptoms only for the patient to wait, and later go in and see the doctor and repeat the whole narrative to the physician. The patient also has to go to the pharmacy first to find out the cost of drugs then go to the cashier and pay before going back to the pharmacy and waiting once again, to present the receipt of payment before getting his/her drugs. All these stop-and-wait points create congestion in the hospital in addition to slowing down the service process, thus creating bottlenecks. For patients that need specialized care, time is wasted and often proves fatal, when doctors have to come in from a 2-mile center to treat traumatic accident victims. This is very costly both for the patient whose life is at stake, and for the hospital that faces risks of patient negligence lawsuits.
Planning of the Processes
Regarding the problem in the case study, the process of patient care is not planned. Whenever there is a patient that needs to have a neuro-ortho procedure, the specialist doctors have to be called in from their station, which is 2 miles away. The Jasmine Hospital caters to 5 patients on a daily basis with the numbers doubling over the weekend yet, even with this consistent flow of patients, the hospital still has to wait for experts to come in from the specialist facility. Because the surgeons are most times already tied up in surgery, patients at Jasmine have to wait for 2-4 hours before being attended to. Thus, the process is more of a first-come-first-served, supply-demand service as opposed to one that is well thought out and planned.
Personnel Involved in Each Step
The main personnel involved are the clerks who register patients at the hospital and who allot ward beds. The nurses that care for the patients at the ED, ward, and surgical theatre. The specialist doctors that perform the surgical procedures and the surgical team from Jasmine Hospital. Other personnel involved are the pharmacists, nutritionists, and physiotherapists who play their role after the surgical procedures are done.
Time Estimates for the Steps
The patient takes approximately 20 minutes to fill in a form with his/her details, including medical history and other demographic information. It takes another 5-10 minutes before going in to have the vitals checked by a nurse at the triage. The triage nurse will take 5-7 minutes to take the patient’s vitals and ask questions regarding the patient’s symptoms. The patient will wait for 15-20 minutes or at times, 30 minutes to go to the doctor’s room. Another 5-8 minutes is spent at the pharmacy as the patient waits for their prescriptions to be packed. If the patient has to pay with cash, he/she will take another 7-10 minutes at the cashier before coming back to the pharmacy and spending another 4-5 minutes waiting for the prescriptions to be packed upon verification of the payment receipt.
When it comes to critical patients, the patient’s family will take around 20 minutes to enter the details of the patient. Meanwhile, the patient will be attended to as fast as possible by the ER nurses and doctors to ensure that his vitals are stabilized and the patient is no longer at risk. At the same time, the hospital clerk will contact the specialist physician and alert him/her that there is a patient at the Jasmine Hospital who needs an urgent surgical operation done. If the specialist physician is available, he/she will come over to the hospital. While waiting for the specialist to come, the surgical room nurses prepare the patient for the procedure while the rest of the surgical team prepares for the same as they wait for the doctor. If the specialist doctor states that he will be late to arrive, the patient is not prepared for theatre but instead is monitored by the doctors at the Jasmine hospital as well as the nurses until such a time when the arrival of the specialist is confirmed as nigh. Hence, the specialist can take between 2- 4 hours on average to arrive or longer.
New Goals for Being Timelier
To reduce on time spent on waiting, Jasmine Hospital will need to work with its HR department (Naik et al., (2012). First, the hospital will need to improve its patient records system. The hospital has to integrate a biometric patient information system that captures all the data, including the medical history of the patient. The 80,000 people in the community can easily be included in the EPR, and this would eliminate the need to have the patient fill in paper forms upon every hospital visit. The clerk at the reception will also have an easier time not having to transfer information from the sheets of paper to the computer system.
The EPR will also need to integrate the preferred patient payment method, and the prices for drugs will be displayed immediately after the physician enters them in the patient’s record. The physician will then tell the patient how much he/she should pay, and the patient will go straight to the cashier and then to the pharmacy. Upon payment, the cashier will send a notification to the pharmacy concerning the payment made. When the patient gets to the pharmacy, he/she will find the drugs already packaged or in the process of being packed.
Additionally, the hospital will need to write contracts with the specialist doctors that offer attractive remuneration for them to work exclusively at the hospital premises from 10 am-8 pm weekdays and from Friday 4 pm to Sunday midnight. The hospital will sign contracts with approximately 6 specialists who will work on a rotational basis. This way, the doctors will not lose out on their private patients at the specialist center, and also, there will always be three doctors available at the Jasmine Hospital, every day. Hence, at any given time, a specialist doctor will spend at least 3 days at their private practice and another 3 days at the Jasmine Hospital.
Educational Needs for the Stakeholders
HR will need to train the relevant staff on the use of the new recording system. This will include the reception clerk, the nurses at the triage, the physicians, the cashiers, and the pharmacy. It will also need to arrange for customer education where patients visiting the hospital will be made aware of the new registration process, its advantages, and an assurance that their bio-data will be safeguarded and not shared by the Jasmine Hospital to third parties. Besides these immediate educational needs, Jasmine Hospital will need to carry out a massive campaign on the need for safety in the community. The key drivers of accidents will need to be addressed (including the use of drugs and driving under the influence of alcohol). Law enforcement will need to be involved in the safety campaigns while the legislative government impressed to enforce stiffer penalties for crime perpetrators.
Duplication/Redundancy in the Process
The clerk has to enter the patient information with every visit, yet most patients are repeat customers. The triage nurses take information regarding the patient’s symptoms and use this to determine which doctor the patient needs to see. It would take less time if the nurses would record the information the patient shares in the system such that by the time the patient goes in to see the doctor, the doctor already has an idea of what ails the patient. Otherwise, asking questions only takes up time. Alternatively, the triage nurses should skip asking questions and instead allocate the patient to the next available doctor.
Measures for Evaluating Improvement
The patients’ waiting time is the first variable that will be measured. Once a patient enters the hospital reception, he/she should pick a waiting ticket that has a time stamp. The clerk will call the ticket number, and when the patient gets to the clerk, he/she will be required to press his forefinger or thumb on the computer identifier so that all his/her biometric information can be retrieved. The patient will thus be recorded as a waiting patient. The information will be transferred to the triage nurse. When the physician opens the patient’s electronic record, the timestamp on the computer will show just how long it has taken for the patient to finally see the doctor. Once the patient is done at the doctor’s room, he/she will also take another ticket at the pharmacy or cashier to record how long it takes to get service at both ends.
With regard to surgical patients, the hospital will record the number of patients attended to in a day/week with the specialists residing at the hospital. The time it takes to attend to a patient will also be recorded and the patient outcomes as well. A successful process will be one where patient waiting time reduces from 2-4 hours to 30 minutes at most. Zero patient mortality will be the preferred outcome as well as reduced cost of patient care.
Sustaining Improvements
As mentioned earlier, the entire community needs to be responsible for its own health and well-being. Jasmine Hospital will spearhead frequent community programs to impress on the need for responsible driving and safer lifestyles. Law enforcement will need to be more vigilant in ensuring reckless citizens are put to book. Within the hospital, the staff will need to go for refresher training every twice a year and be encouraged to give feedback on the efficiency of the hospital patient recording and service systems. Patients will also be encouraged to give feedback on the service provided as well as give suggestions for improvement.
New Arrangements to Sustain Improvement
More staff will need to be employed at the triage, the doctor’s rooms, the cashiers, and the pharmacy. Having two additional clerks, triage nurses, doctors, cashiers, and pharmacists will reduce the bottlenecks in service provision. Additionally, as mentioned earlier, the hospital will sign contracts to have the specialists work in-house throughout the week and on a rotational basis. The hospital will also publish fliers available at the reception for all patients to read. The fliers will emphasize on the need for responsible living and better/healthier lifestyles. The fliers will also contain contact information where a person can get help, for example, drug addiction help, counseling services, police and hospital hotline numbers, among others.
Rewards for Stakeholders
Jasmine Hospital will save on costs when it reduces its patient’s waiting time (Furterer, 2018). The hospital will be in a position to attend to more patients within a shorter time, thus reducing the possibility of patient mortalities as well as eliminating the possibility of malpractice lawsuits. Because the specialist will be in-house, the patient admission time will be shorter; hence, freeing up beds sooner for more patients to occupy. The patient will save on time and get treatment faster. Medication errors are less likely to happen with the new IT system in place. The community will live healthier and safer lifestyles with possible increased lifespan.
References
Campbell RJ (2009). Thinking lean in healthcare. J AHIMA; 80(6):40–43. Quiz 45–46.
Furterer, S. (2018). Applying Lean Six Sigma methods to reduce length of stay in a hospital’s emergency department. https://www.tandfonline.com/doi/abs/10.1080/08982112.2018.1464657?scroll=top&needAccess=true&journalCode=lqen20
JBA (2014). Lean leader certification and maintenance – physician track (FAQs).http://www.sma.sk.ca/data/1/rec_docs/872_2013-2009-2003LLTFAQ.pdf
Naik T, Duroseau Y, Zehtabchi S, Rinnert S, Payne R, McKenzie M, Legome E (2012). A structured approach to transforming a large public hospital emergency department via lean methodologies. J Healthc Qual.;34(2):86–97
Smith G, Poteat-Godwin A, Harrison LM, Randolph GD (2012). Applying Lean principles and Kaizen rapid improvement events in public health practice. J Public Health Manag Pract. ;18(1):52–54.
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Question 
Lean management at Jasmine Hospital
Reading:
Nash, D. B., Clarke, J. L., Skoufalos, A., & Horowitz, M. (2012). Health care quality: The clinician’s primer.
Chapter 22
Harvard Business Review (2011). Harvard Business review on fixing the healthcare from the inside & out.
Pages 161- 202
You are the Chief Quality & Safety Director for Jasmine Hospital in Pine City, Colorado. The community has 80,000 people and is a fairly new community of 25-50-year-old residents who moved in over 10 years time. Your hospital is the primary acute care hospital within 10 miles. There are a large number of sporting injuries and Vehicle accidents that result in a significant number of head traumas and broken bones in the middle through high school age group. Your emergency room is a general trauma ED staffed by ED generalists, but there is a clinic within two miles that has a host of orthopedic and neurology surgeons and neurologists.
Problem: Waiting times for bringing in the specialties to the ED averages 2-4 hours as most of them are in surgery within the hospital, but not available. You have had four deaths in 3 months from not being able to address compound fractures or head traumas fast enough for these teenagers. You average five (5) neuro-ortho cases per day during the week with most of these from 11a-7p each weekday. You also average 10 neuro-ortho cases from Friday at 5p to Saturday midnight each week.
Your job is to prevent deaths and come up with a plan that can address the needs of this community within your ED. Address the following using Six Sigma, Lean thinking, educational needs, and community outreach. Address the following:
- What do you believe the initial problem is?
- Who are the customers (stakeholders) and what do they need? (minimum of 5)
- How would each customer (stakeholder) describe being satisfied in the end?
- What are the current processes being used (you may need to make some of this up)? Be complete. Identify the process from an event to a full or limited but permanent recovery.
- What is some of the identified waste seen in this process? (Imagined waste).
- Are the processes currently planned or unplanned?
- Who are the personnel involved currently in each step?
- Give time estimates for the steps. (may need to create some)
- What would be new goals for being timelier?
- What are the educational needs of the various stakeholders?
- Is there duplication or redundancy adding to the waste?
- What measures would need to be made to evaluate improvements? Are the measurements reliable measures?
- What is needed to sustain these improvements?
- What new agreements would need to be made to sustain these improvements?
- What are the rewards identified for all the stakeholders in this process?