“Keep It Simple Samantha,” (or KISS) I told a good friend as she asked for advice in starting a Lean approach to improving quality at the health care organization where she is an operations manager. Lean is a popular approach used to look for ways to improve the efficiency and effectiveness of processes in organizations. The Lean approach does this by searching for ways to root out waste or “non-valued added” activities to save time and costs at the same time being more responsive to customers.
Samantha (Sam) also wanted to get greater employee involvement in the work setting as she told me, “These are the boots on the ground. If anyone knows how to make things better, it is the person that is involved in the job day to day.” I suggested that she create teams to work on problems because (taking a line from the Weather Underground TV show) “together we know more” and the teams will help encourage each other to keep at it and suggest ideas for improvement. I then suggested Sam use the following simple seven-step approach to introduce the Lean to the each team.
Step 1: Define the Problem
The team needs to define the problem in a way that does not make judgments as to cause. That comes later. The team needs to think through causes to find the right solution rather than symptoms. An example of how one time defined the problem, one of Sam’s teams decided to work on reducing the time to transfer patients from the emergency department (ER) to a given inpatient floor. As the team talked about the problem, they soon realized that what seemed a simple problem initially, became very complex as the different elements that would affect a move from the ER to Intensive Care Unit v Obstetrics v Pediatrics v Gerontology. So they decided to choose one unit, Intensive Care, in order that they could look closely at one unit. Sam said, “The team realized that they needed to focus on one problem they could tackle instead of getting mired down in a problem that would take a much longer time to solve. They simply did not have the resources to commit to solving the bigger problem. Sam said, “They took a bite out of the elephant instead of trying to eat the whole thing on one setting and that was good. They were more focused, I wanted them to be successful in what they did and not get stuck in the weeds.” Sam was spot on.
Step 2: Measure the Problem
Sometimes we think a problem is a problem when it may not be that big of a deal. So measurement is important. Coupled with defining the problem, the next question is “how do you know it is a problem, what data supports that it is a problem?” In Sam’s team, they measured the number of minutes it took from the time the doctor indicated the patient could be transferred until the patient had a room in the Intensive Care Unit. They decided to include the time from when then patients were on the Intensive Care Unit (ICU) until they were in a room as important as there were some significant delays in that part of the transfer that they wanted to capture. While it may not been such an issue in the ICU unit, the team wanted to have a measurement process that could be used as they later looked at other departments.
Step 3: Mapping the Process
Well Sam did not say, “Now it is time to map the process.” The team would have choked, as they did not think of what is done as a process. But Samantha was smart enough to simply say, “Ok, now write down each step that is done by each person involved from the time the doctor indicated the patient could be transferred until the patient has a room in the ICU unit.”
This is called “mapping the process.” This is an important step to help the team understand what is all involved in the process so they can start analyzing and understanding the potential issues that may be wasting time and costs in the process. As part of the process, it would be helpful if the team collected data related to the time it took for each step (maybe the average time for several weeks and looking for particular days where there are greater number of transfers occurring or if there are differences over particular shifts or times during the shifts). The importance of how the data was collected is critical because that information may help to find a cause of the problem and help find a solution.
Step 4: Analyze the Data
Samantha and I agreed that each team should look a two key items during their analysis of the data – the process map itself and do a root cause analysis.
What is the process map telling us? – We wanted the team to look at the process map they created and consider what could be changed to reduce wasted time and cost. We had them ask three questions that could be asked for each step: Did it add value? If not, why are we doing it? If it did add value, was it for the organization’s benefit or the patient’s benefit? From the answers to these questions, the team started to consider where changes could be made. But, we also wanted to analyze what are some of the sources of wasted time and costs. For that the team did a root cause analysis.
Root Cause Analysis – This approach is also called a Cause and Effect Diagram, Fishbone Diagram or Ishikawa diagram (based on the person who first introduced this approach, Kaoru Ishikawa in 1968). Sam had the team draw out a diagram that identified root causes rather than symptoms that delayed the transfer from the ER to the ICU. Then the team would discuss the results of the diagram and make suggestions how the process could be improved to reduce some of the more critical causes. An example of a Cause and Effect Diagram appears below. While not for the Sam’s team focus (a client privacy issue), the diagram below will give you a sense of the level of detail that should be included on the diagram in order to make it helpful as a tool to improve a process. This example is for finding causes for packages missing their connections at a package delivery company.
Step 5: Improve
From the analysis above, the team then developed solutions to improve the time and costs associated with transfers from ED to the Intensive Care Unit.
Step 6: Check for Improvement Change
A major part of the Lean approach is management by fact. So Samantha had the team check to see if their changes had an effect on the overall measure and the measures they took of specific steps in the process map.
Step 7: Making the Change Part of the Culture
People are use to the way they have done things in the past, so part of the change process will focus on changing the checklists, SOPs (Standard Operating Procedures), or reinforce those who use the changed process to follow the new approach.
KISS & Lean
Lean need not be a complicated approach. “Keep It Simple Sam” (KISS) to start off the approach will get more employee acceptance than if the approach is filled with all the jargon that consultants like to add to the approach. Getting employees involved in the change process gets them engaged and better acceptance and better decisions of what needs changing as they are the boots on the ground. Later, as they better understand the approach we can add more sophistication to the Lean process.