A Magnet™ organization goes lean, with nurses playing a key role in the culture change.
Hospitals increasingly are implementing quality-improvement systems based on “lean” principles derived largely from the Toyota Production System (TPS). This system, which divides all manufacturing activities into those that add value and those that create waste, aims to eliminate waste and maximize value.
Lehigh Valley Health Network (LVHN), a 988-bed Magnet™ organization in eastern Pennsylvania, is committed to a formal approach of lean methods, termed the System for Partners in Performance Improvement (SPPI). The goal is to discover more efficient ways to provide health care by using lean tools and concepts that reduce waste and repetition. SPPI aims to identify and remove obstacles to service delivery using two simple concepts: (1) respect for people, patients, and society; and (2) continuous improvement. Focusing on these concepts guides LVHN staff to deliver excellent care while reducing costs and improving efficiency.
LVHN services a population of about 700,000. Its nearly 10,000 employees include approximately 2,400 nurses. In 2008, it embarked on the SPPI journey, which built on the existing culture of performance improvement. SPPI allows nurses at all levels to influence changes throughout LVHN—a key characteristic of a Magnet organization.
TPS concepts have been used in the business world for decades and have become popular in health care. Healthcare leaders believe patients are willing to pay for quality care—that they go to the hospital to be diagnosed, treated, and discharged, but aren’t willing to pay for more than that (deemed waste).
So how do you remove waste from hospital processes to improve efficiency and patient outcomes? Before waste can be removed, it must be identified clearly. TPS identifies seven non-value-added wastes in business. In his 2009 book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction, Mark Graban modified the definitions of these wastes to apply to health care. (See Eight wastes in health care by clicking the PDF icon above.)
Defining a value stream
The journey to go lean begins with defining a value stream—the specific process used to provide a service to customers. To do this, LVHN’s senior leadership had to answer such questions as: What do patients want from LVHN? What are they willing to pay for? As they did so, they defined a value stream focusing on improving access and use of services. Then they broke this concept down into value stream 1, which centered on inpatient services, and value stream 2, centering on perioperative services.
Once the value streams had been defined, the new goal was
to make value flow seamlessly through all departments to ensure excellent, efficient care. Each unit or department has a specific function; interactions among departments can make or break the patient experience. All areas and departments affected by a process must participate in strategies aimed at removing waste and improving efficiencies.
The five days of an RIE
To improve the value flow, the SPPI process used rapid improvement events (RIEs) for each area identified in the value stream. An RIE is a 5-day, continual-improvement event geared toward identifying wastes in a process, developing and testing possible solutions through experiments, and implementing changes to improve service to customers.
The RIE was conducted at the site of the problem. Members selected for each RIE included frontline staff and management from all units involved with the process, as well as “outside eyes” (persons with no direct involvement in the process change). Value stream 1 consisted of seven different RIEs.
Throughout the RIE process, lean tools and concepts were used to detail the current state, conduct experiments, and develop processes to achieve the target state. (See Going lean: Tools and concepts by clicking the PDF icon above.)
For each day of the RIE, participants strove to accomplish a specific goal:
Day 1: Define the current state—the process taking place at this moment.
Day 2: Create the target state—where you want to be, the direction in which you want to go. The target state may not be your final result because it evolves over time; at some point, it becomes the current state again and the process begins anew. Experiments (solutions or countermeasures) are developed to eliminate waste.
Day 3: Take action by testing the experiments developed on day 2 to achieve the target state. Some experiments may fail, but these failures let you tweak the countermeasures to find what works best.
Day 4: Identify the process that effectively eliminates waste and improves the value stream. Finalize the new process and develop standard work to achieve the target state. Identify metrics to measure the effectiveness of the new process.
Day 5: Report to the organization and celebrate successful RIE completion. The team shares the new process and standard work done to achieve the target state. Information sharing is crucial to sustaining changes. However, check-ins must be done at 30, 60, and 90 days, when necessary changes can be made. The “feed forward” process continues with each change to ensure the target state becomes the new current state.
Lean principles in action
One area of needed improvement identified in value stream 1 was inpatient physical discharge. Here’s how LVHN used the RIE process to improve the discharge process.
Day 1: Participants identified key discharge problems. These problems included lack of a standard discharge process and a majority of discharges occurring in the late afternoon, which created significant capacity issues. LVHN needed to establish standardized discharge expectations—not only for patients and families, but also for nurses and physicians.
The current state was further defined using the following metrics:
- average acute length of stay: 5.7 days
- 5% of discharged patients left before 11 a.m., even though 46% of discharge orders were written or entered before 11 a.m.
- average “order to discharge” elapsed time: 3.05 hours
- 34% of discharges completed within 2 hours of order
- 75% of discharges occurring after 1 p.m.
Clearly, a communication gap existed among the interdisciplinary team, which caused a delay in discharges.
Day 2: Participants determined the target state to delineate how the discharge process should be conducted to eliminate waste. Improvements in flow, patient satisfaction, and utilization were the desired outcomes.
- Flow: Develop a standard collaborative discharge process to promote efficient communication among all multidisciplinary team members.
- Patient satisfaction: Increase patient and family satisfaction with the robust discharge process.
- Utilization: Involve multidisciplinary team members at the patient’s bedside, including staff from all shifts.
Next, the RIE team applied lean tools. A communication circle showing everyone involved in the discharge process was created to illustrate all interpersonal communications. A gap analysis was conducted by shadowing staff during the discharge process to identify where and when most discharge work occurred. When the RIE group analyzed the information gathered using lean tools, it became obvious that the discharge workload needed to be leveled out among all shifts and communication needed to be more frequent and more efficient.
Days 3 and 4: Participants tested proposed experiments, which included posting door signs indicating a potential discharge, using a discharge checklist with assigned tasks for each shift, and instituting collaborative discharge rounds. The checklist included such items as resolving or completing care plans, conducting patient education, and reconciling patient belongings. A color-coded key on the checklist identified which tasks the discharging nurse must complete and which tasks other nurses could complete. Thus, on the day of discharge, it would be clear which tasks still needed to be resolved before the patient could be discharged.
Throughout the RIE process, participants indicated that we needed to work at communicating better with each other. A successful experiment to help establish this was implementing a daily rounding process at 10 a.m. involving nurses, physicians, physician assistants, and case managers to discuss patient discharge plans. This procedure has been invaluable, further ensuring timely discharge and enhancing interdisciplinary communication.
Day 5: “Feed forward” occurred. Successful experiments and newly developed standard work were reported to all of LVHN. Follow-up at 30, 60, and 90 days continued to show the new discharge processes were effective and the target state had been achieved.
Value stream 1 outcomes
Overall, the SPPI effort at LVHN has reduced length of stay, improved patient satisfaction, decreased emergency department (ED) diversions, and reduced time from the ED to the bed. (See Value stream 1: Outcome metrics.)
Although work remains to be done and new processes to further improve metrics continue, lean thinking has become enculturated among all LVHN staff. Many staff members now use these techniques throughout all aspects of their work. Living the RIE process has given staff at all levels a better understanding of organizational processes.
As a Magnet organization, LVHN ensures that nurses stay at the forefront of organizational change. The lean tools and concepts used since SPPI inception have become part of daily nursing practice. The integral role nurses have played in SPPI is another example of what it means to work at LVHN. Going lean is a journey—one that allows us to continually improve our health network and the way we provide care to the community.
Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY: Productivity Press; 2009.
Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. New York, NY: McGraw-Hill; 2003.
The authors work at Lehigh Valley Health Network in eastern Pennsylvania. Kimberly T. Korner is director of patient care services. Nicole M. Hartman is a nursing excellence specialist. Angela Agee is a staff nurse in the medical-surgical unit. Maria McNally is a patient care specialist in the medical-surgical unit.