How Hospitals Continue to Zap Waste

Continuous improvement techniques used in manufacturing have helped at least six nationally recognized hospitals reduce wait times and drive up HCAHPS scores.

The management principals behind a car maker's success can drive down long wait times in hospitals, revving patient satisfaction rates and HCAHPS scores in the process.

A discussion paper published by the Institute of Medicine suggests that patient wait times can be decreased and patient satisfaction improved by using well-known continuous-improvement approaches frequently found in industrial engineering and manufacturing trades.

Long wait times are a systemic problem that contribute not only to poor patient experience and create a barrier to accessing care, but also contribute to burnout among healthcare professionals, says Lisa Brandenburg, president of Seattle Children's Hospital, and an author of the paper. Other authors represented Denver Health, Mayo Clinic, Geisinger Health System, and Kaiser Permanente.

"Everyone comes to work wanting to take great care of the patients, not searching for supplies, spending lots of time looking for information, or duplicating steps that don't need to be duplicated... All of us in healthcare want to spend more time serving the patients," said Brandenburg who was reached by phone.

Additionally, the paper found that long wait times drive down HCAHPS scores.

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Continuous Improvement
A key component of Seattle Children's care redesign is the management practice of continuous improvement, which is also known as the Lean process, Kaizen, or the Toyota Model. It has been widely adopted in manufacturing. Brandenburg says her hospital adopted it about ten years ago.

Seattle Children's Hospital's leadership, along with the leadership teams from other hospitals associated with the paper made it a mission to observe their surroundings and look for ways to improve them, focusing on eliminating wasted time from their systems.

"Healthcare has many steps that would be considered waste—things that do not add value to the customer," says Brandenburg. One example: A nurse searching for the right tool to do a procedure correctly. A remedy is having each nurse bring to the OR the supplies he or she needs rather than wasting time looking for them.

Brandenburg and her colleagues argue that long wait times in healthcare will require a remedy that is focused on improving the efficiency of scheduling systems and take into account the laws of supply and demand.

Recognizing that demand is flexible, the organization has attempted to make its supply of clinicians more flexible, taking in to consideration trending data on demand that is recalculated daily in real time.

Using this data, Seattle Children's has been experimenting with different methods for making its clinicians more available to patients. A few approaches:

• Improving communication regarding scheduling backups before they become severe, to prevent problems from growing unchecked
• Scheduling nighttime appointments for physicians who also teach classes during the day
• Improving transparency around wait times. Seattle Children's now posts wait times for every clinic in hospital lobbies so patients know to expect.

These efforts have brought the wait times for the hospital's specialty clinics down to 12 days from 18. Since the improvement is intended to be continuous, it won't end with these changes, says Brandenburg. "We want to be at seven days…. But we can continually make improvements and continue to take waste out of the system, including search time, travel time, transport time, and excessive complexity," she says.

A Proactive Approach
One commonly raised concern is that while most departments in a hospital can strictly adhere to a schedule, the emergency department can't—after all, no one schedules a heart attack or accident.

Through use of computerized monitoring and improved planning, however, Seattle Children's has been able to beat long wait times in the ED.

The hospital once had a reactive approach to incoming ED patients, it now uses metrics and a dashboard to track patient influx and throughput, then it uses that information to predict wait times. Once the predicted wait times reach a level that could escalate to intolerable, the hospital staff calls in more clinicians. "Once the level gets to orange, we begin asking ourselves, 'what else do we need to do right now?' says Brandenburg.

The goal is to stop bottlenecks before they start. The result has been a 25% improvement in patient flow for admitted patients, as well as decreased wait times for patients who do not require admission.

Other areas marked for improvement through the Continuous Improvement process have included improving parking availability, the patient registration process, the discharge process, and time-to –obtain-a-procedure.

Now, says Brandenburg, with some waste out of the way, hospital staff can focus on what they do best—help the patients. "Everyone involved has a shared belief that it's possible to create high quality, high value experiences for the patient with less waiting and more patient-focused care," she says.