NC Rural Hospitals Lean Together to Zap Waste

When Lenoir, North Carolina-based Caldwell Memorial Hospital first signed on to be a part of the Western North Carolina Rural Hospital Lean Collaborative,president and CEO Laura Easton didn't think they'd find much to trim. 

"None of us want to believe we have waste. I didn't believe we had waste," Easton said in an interview with HealthLeaders Media. "I thought we were so lean and mean there was no way we were going to find anything."

"I found out, in our process, that we had a guy who worked full time as a lint remover. He just used a lint brush and [removed lint from towels] for the operating room," she remembers. "Or that we had six people who just scan things all day long, just scan papers. You just find things and you had no idea. You're not even that big; you thought you knew it all."

With the help of the North Carolina Hospital Association, a consulting firm, and a grant from the Duke Endowment, Caldwell Memorial Hospital teamed with four other hospitals to learn how to apply lean management principles. The hospitals shared ideas and resources, including funding and consulting services, and attended each other's learning events.

Lean management is relatively straightforward: Eliminate waste within the organization. But not all waste is as obvious finding a new job for the lint brush guy.

The process works by focusing on specific value streams within the organization and performing a series of "rapid improvement events" which map out the entire workflow, identify areas of waste, find places to trim, and apply a new process.

Caldwell Memorial Hospital chose first to focus on its surgical value stream and trimmed everywhere, from cleaning out the physical waiting room space, to positioning tools exactly where they'd be needed, to creating "admit packs" so the patients' gown, bonnet, and booties were laid out and ready for them on the bed. As a result, they've reduced patients' surgical prep time by 60%.

Performing such a granular analysis of a value stream takes more than employee buy-in; it takes everyone being onboard and honest with themselves about their processes.

"It's remarkable to watch employees sit down and map out issues and discover possible solutions in a team environment and then have the wherewithal and the authority to implement these changes and see if they work," said Edgar Haywood III, president and CEO at Dosher Memorial Hospital, which is part of the new Eastern North Carolina Rural Hospital Lean Collaborative. The eastern collaborative was formed after the success of the western collaborative.

In addition to employee involvement, creating a truly lean institution requires a hands-on approach from the hospital CEO. Easton said the process will fail without complete CEO involvement.

"This is not something that you can delegate to one of your executives," she said. "I think lean is only really appropriate if the CEO is committed to changing the way they operate the organization, and learning too, and being part of running their organization in a new and different way."

Haywood says he agrees, and that lean is "a bottom up movement, but it's got to have top-down endorsement."

"It doesn't mean, 'you go to this meeting,'" he said in an interview. "It means, 'I'm at this meeting and you follow me.'"

So what does it mean to be a hands-on CEO? Haywood said that he spends a minimum of 5-6 hours per week dedicated to some form of lean training. Easton said she began her hospitals' lean journey with weekly e-mails to each of her managers "trying to indoctrinate them into the lean way of thinking."

Because in actuality, "lean" seems to be as much a mindset as a strategy.

"It's a philosophy; it's a whole way of looking at the work," Easton said. It's not always easy to get everyone onboard, but it helps when the CEO is, as Haywood calls himself, the "head cheerleader."

"I'm an old dog," he said. "But I sure can tell you they can be taught new tricks."

Even though the hospitals in both collaboratives are still working on trimming the waste in their organizations—becoming truly lean can take years—they're already seeing big results.

"Over time you just see that your top metrics have really moved," Easton said. "You have higher satisfaction, you have reduced staffing, significantly less dollars that you're spending, your expenses go down, your physician satisfaction is better. We have much improved on-time starts."

Add to that, Haywood said, improved patient satisfaction. In just a few months of trying to improve its surgical value stream, Dosher's measured outpatient satisfaction has been at 100% for several months.

"It makes everybody focus on that reason we're all in business, that patient, and what kind of experience they're going to go home with," he said.

Both CEOs agree that big or small, every institution has to figure out how to operate more efficiently while keeping patients safe and happy.

"We've got to do more with less," Easton said. "Not just by squeezing the orange harder, but by redesigning the orange so that you don't have to squeeze it."