Following up from the summary of the last blog: "The essence of this article is to take a look at a room. Not how pretty is it, but how much waste is there in that room, how confused is the flow? What is the body fat content of your organization? Is it obese or lean? Does your facility lend itself to be high performing in utility usage, staff usage, time usage, supply usage? Is it efficient in all manner of flow, from the patient, to the clinicians, the meds, the supplies, the equipment, the processes in the rooms and departments and the flow of communications and data?
The economic times we are living in are reinforcing a focus back on quality, not it terms of how absolutely perfect can we make or do something, but rather how can we harness all of our resources to achieve the best ends possible. Harnessing. All of our resources. Achieving. The best ends possible. These phrases all have one thing in common, even as standalone phrases, and that is process. What is the way we do things? What is the structure of how we organize things? How do we reinforce and focus our purposes? How do we stair step our results to elevate the total quality of healthcare performance we provide to our communities?
Way back in 1869 the chemist Dmitri Mendeleev had an insight into the recurring ("periodic") trends in the properties of the atomic elements. He developed a table that organized these elements by the trends or patterns he observed in their sub-atomic properties. The table was not perfect, there were holes between various elements, but because the recurring trends were consistent, other chemists were able to begin a search for the 'missing elements', and find them! The layout of the table has been refined and extended over time, as new elements have been discovered, and new theoretical models have been developed to explain chemical behavior. The periodic table is now ubiquitous within the academic discipline of chemistry providing an extremely useful framework to classify, systematize and compare all the many different forms of chemical behavior.
Wisdom provided insight into a random assortment of knowledge based facts and began to recognize trends and patterns. As these trends were seen and understood more clearly, a thinking process began to establish relationships between the elements: the random became structured, the mystery became revealed. And upon the foundation of the periodic table additional insights came to light, knowledge was discovered, understanding increased, and the application of those truths began to elevate chemistry to higher levels. How high? Google it on your cell phone!
Performance, or results, used to be judged by the concept of conversion. "Conversion - labor and materials are converted into products: input into output". Wood with craftsmanship created a chair, the farmer planted seed and harvested a crop. The 'quality' of these results was evaluated by several elements. How much labor and materials were required? How much of the materials were wasted (cutting a 3'-0" circle out of a 4x8 sheet of plywood)? How long did the conversion process take? Did the product meet the desired ends in function? Did it last, was it sustainable, or did it breakdown prematurely? But primarily (in the simplest of terms), quality boiled down to the conversion of labor and materials into products and the cost per unit and the return on that investment. In healthcare lingo, how many patients do we see, and how much can we bill?
What the conversion model failed to recognize in the production of products, and the seeing of patients, are the invisible elements of the flow process: the moving, waiting, inspecting and the host of other activities that added no value to the product, but added cost. And a cost that is directly unrecoverable, or in attempting to recover it causes the cost of the product to increase to the consumer, and then the dynamics of market competition come into play.
In terms of healthcare design, let me illustrate with a common example of a typical ER visit. The patient enters the ER and is seen at the Triage station, and then goes through the admitting process. When a room is available they are taken into the department, and vital signs are taken, a preliminary diagnosis is done and a course of treatment is determined. Lab work may be done. Radiology work may be done. IV's may be administered. And there may be more extreme measures taken due to the acuity of the situation. All of these activities are conversions: they are the utilization of labor and technology and resources in direct interaction with the patient, and they are billable. In-between these conversions are the flow processes: waiting, moving or transporting the patient (or blood samples, x-rays, etc), inspecting and reading the lab results, or x-rays, consultations, etc. The 'total quality' of the ER visit may take 2-4 hours, the 'actual quality' of all of the conversions might be accomplished in 15 minutes.
Lean healthcare design is removing the waste between the 15 minutes and the 2-4 hours. Again, you can Google this on your cell phone, or drive down to the library and wander up and down the aisles looking for books that might have a paragraph or two to help you understand the process. Lean design in all aspects, from manufacturing, which is widget oriented, to healthcare, which is performance oriented, is based around the concept of the flow of processes.
The patient room described in the last blog was not an attempt to slam another design professional, but was a 'design MRI' of the patient room flows. The placement of every item in that room is a conscious decision that has a direct impact on flows. A hospital is not a static organization, like a bank, or movie theater, or stadium, or school. In those organizations, your flow process and conversions are pretty basic and direct, and the quality is very controllable, i.e. a movie in an Imax 3D theater. A hospital is like the human body it treats, it is a living, moving, interacting organization of multiple systems all converging in their performance and treatment of a patient. As a result, every tangible items affects the flow and process (where is the wheel chair or IV pump) as well as intangible items as the documentation into medical records.
These arrangement of processes affect the delivery of the treatment, and the quality of that treatment. Does the evaluation of the lab result have a determination on what radiology tests need to be done? Which comes first? Much of this is dependent on the thinking and diagnosing process of the clinician based upon their evaluation of the patient... and the additional information as it becomes available. Lean healthcare is a continual improvement of the thinking process in all aspects of healthcare, and as things are more clearly thought out and understood it affects the placement of all items and procedures and tests and processes. Our thinking shapes our facilities, they can be whatever we want them to be. But our facilities shape our further thinking and performance processes.
Lean healthcare thinking is a 'design process' that is a two-edged sword that continually looks at what you are doing and how you are doing it and carves off the waste. How lean can we go? How much can we improve our quality and efficiency in all of its aspects? Google it on your cell phone while you are waiting on your food in the restaurant!