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Archive for category: Lean Six Sigma

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5S: How to Organize and Optimize Work Areas

5S is a basic lean tool for organizing work areas for efficiency and effectiveness. Because of its simplicity and universal applicability, it’s oftentimes used as a beginning LSS project. 5S, from the Japanese words seiri, seiton, seiso, seiketsu, and shitsuke, is often translated to Sort, Set, Shine, Standardize, and Sustain. It describes a simple, thoughtful process to organize, clean, and maintain a work area for optimal efficiency.

The Stages of 5S

Sort

Work areas should only contain what is needed. Oftentimes, however, these areas are overloaded with items rarely or never used. Sorting items allows you to identify items that aren’t used (and dispose of them) or rarely used (and move them). It’s tempting to keep items because you “might” need them at some point. Attach a red tag or sticky note to items not used frequently and set them on a designated table. If the item is used in the next month, remove the red tag and keep the item. If not, move or discard the item.

SET

Set (in order) is the organization phase. Everything should have a place, and the places should be determined by the most logical arrangement. Usually this means that objects are organized by type, and rooms are organized by arranging the most frequently used items closest to the person needing them. In a storeroom, this means organizing items in logical groupings and then placing the most frequently accessed groupings nearest the door. While saving a few steps might not seem like a big improvement, its effect can add up.

SHINE

Shine is the cleaning phase. All areas should be clean at all times. Disorganized and dirty areas create waste by obscuring needed items, decreasing workplace safety, requiring additional or repeated cleaning time, or simply by contributing to a disorganized mindset in a team.

STANDARDIZE

Standardization is the labeling and systematizing phases. Items should have clearly marked spaces. Use large, easy-to-read labels and colors to group types or categories. Create keys or legends for large storage areas.

SUSTAIN

Sustain is the perpetuating phase. Organizing a 5S event is not meant to be an annual “Spring Cleaning.” Instead, it should create lasting, sustained organization through design, training, and maintenance. Labels, color-coding, and other systems established in the standardize phase must be kept up. There must be a plan for keeping the area cleaned. Everyone on the team must be trained in not only where to find things, but also how to store things. Finally, there must be routine monitoring and follow-up. This doesn’t mean a manager needs to audit a work space or storage area every month. In fact, systems are usually more sustainable when auditing is delegated to team members and rotated. Create a simple checklist and have a different staff member complete it each month.

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Lean Six Sigma and QAPI: Complementary Initiatives to Improve Quality

Lean six sigma is a perfect methodology to comply with the upcoming CMS mandate for QAPI (Quality Assurance and Process Improvement). By combining a rigorous, resident-centered, project-based process improvement philosophy with existing quality assurance program data, providers can not only meet CMS regulations, but also put in place a program that will generate true value for residents by focusing on improving quality and reducing waste in the pursuit of excellence.

Lean Six Sigma and The Five Elements of QAPI

Element 1: Design and Scope

Lean six sigma programs, by design, encompass an entire organization. Indeed, to be successful, lean philosophy must become ingrained in the organization’s core leadership and mission. Providers must commit to relentlessly eliminating waste by practicing continuous, systematic improvement. By promoting a culture of improvement and developing people to understand and create more value in their work, lean six sigma programs also help ensure “everyone is on board.”

Element 2: Governance and Leadership

QAPI requires that the governing body and administration commit both in writing and in practice to a culture of quality improvement and excellence. A lean six sigma program starts with acceptance and promotion by the governance structure and is most successful with active administrative support. Lean six sigma takes leadership a step further and commits to a method of problem solving that respects people and creates lasting value in pursuit of the organization’s mission.

Element 3: Feedback, Data System, and Monitoring

Built on the principle of continuous improvement, lean six sigma programs provide a rich framework to monitor quality, measure improvements, and maintain gains. By focusing on data, lean six sigma is primed for compliance with QAPI. Further, by creating systems of quality and cultures of active participation and respect, lean six sigma can help organizations move quickly beyond traditional nursing metrics and look at value creation opportunities in dining, marketing, and ancillary services.

Element 4: Performance Improvement Projects

By integrating Six Sigma project discipline, improvement activities will already by organized into measured, documented projects in compliance with CMS standards. While lean six sigma promotes continuous improvement, most focused activities are completed in projects, either through a DMAIC process or with A3 thinking, meaning organizations will be well prepared to demonstrate effective improvement project outcomes.

Element 5: Systemic Analysis and Systemic Action

Lean six sigma culture, through documented quality improvement, ensures an organization strives forward. As hospitals and health systems look more and more to partner with organizations that can prove their value, a lean six sigma base provides hard data on organizational excellence. Further, the program allows organizations to quickly attack any problem area with a focused, universal improvement discipline, increasing teamwork across functional silos and generating a stronger sense of togetherness across the organization.

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No Layoffs

I recently attended the American College of Health Care Administrators Convocation and was very intrigued by the session on Lean in long term care. While the presentation provided a solid overview, I was dismayed when the presenter mentioned that after an initial lean deployment, a nursing home operator eliminated almost 15% of its staff due to efficiencies gained.

In LTPAC, where margins are constantly being squeezed, there is always temptation to make cuts as soon as capacity allows. Acuity-based staffing, albeit temporary, is a symptom of this practice. Unfortunately, cutting staff first puts short-term financial gains ahead of long-term value creation, and stifles an organization’s ability to innovate practices and lean value into operations. It also creates an adversarial atmosphere where management constantly tries to limit costs and employees try to protect jobs no matter the cost to the organization– both without regard to what’s best for residents!

“We’ve also made a commitment to our staff that there will be no layoffs related to this work. This frees them to concentrate on process improvements without worrying about continued employment. Once staff have the opportunity to experience the power and potential VMPS holds for our organization, they are excited to use the tools to improve work in their own areas.” – J. Michael Rona, President, Virginia Mason Medical Group

At the beginning of a lean journey, it’s crucial that organizations commit to a “No Layoff” policy, as Virginia Mason did when first bringing lean into healthcare. Without such a commitment, it is nearly impossible to engage front-line staff in identifying opportunities to eliminate waste, since staff will more likely be interested in protecting their jobs rather than leaning themselves out of one. Fortunately, there are numerous areas where labor can be redeployed to improve quality, increase offerings and otherwise contribute to enhancing revenue and decreasing costs (long-term value creation). What’s more, because lean places such an emphasis on the resident at the center of the value process, employees better understand that they work for the residents and the organization as a whole, rather than individual departments and silos that is all too often the reality in current environments; this makes the process of labor redeployment much easier.

Through the process of attrition, sometimes workgroups themselves will step forward and indicate that a position might not need to be refilled. In these cases, redeploying the wage resources into existing employees can be an effective way to enhance recruitment and retention, particularly in low-wage positions, and organizations oftentimes see savings almost immediately in lower turnover costs and higher productivity yields.

One of my first lean projects involved such an approach. By combining two separate food-service programs on a campus into a single entity, and redesigning workflows to maximize efficiency of different job classifications, we were able to begin a 24-hour dining program and raise staff wages while still creating $50,000 of hard cost savings in the first year.

A “No Layoff” policy is a crucial underpinning of the beginning of a lean journey, and embodies a true respect for people that is so critical to the success of any lean endeavor.

 

 

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Respect For People

At the core of Lean thinking is the concept of Respect for People, and it’s this part– more than continuous improvement and elimination of waste– that makes us believe Lean has so much to offer the long-term and post-acute care environments. Many nursing homes and assisted living communities have already engaged in culture change activities over the past several years, and one of the most crucial elements to success– as well as a benefit in and of itself– is empowering and engaging line staff in the change journey. Lean can complement and strengthen this area, and serves as a link between organizational philosophy and quality improvement activities.

Respect for people is altogether both simple and difficult to understand and implement. For most healthcare organizations, respect means treating employees fairly, providing adequate training and supervision, and providing a safe and stable working environment. In Lean, respect for people is much more involved; it means line staff are understood to be experts of their work areas, supervisors and managers spend time on the floor with line staff, all employees are involved in problem-solving, and errors are generally assumed to be system-induced.

The problem solving process is a key example used in describing respect for people from a Lean perspective, as noted in this e-letter from James Womack, the founder of the Lean Enterprise Institute:

Managers begin by asking employees what the problem is with the way their work is currently being done. Next they challenge the employees’ answer and enter into a dialogue about what the real problem is. (It’s rarely the problem showing on the surface.)

 

Then they ask what is causing this problem and enter into another dialogue about its root causes. (True dialogue requires the employees to gather evidence on the gemba – the place where value is being created — for joint evaluation.)

 

Then they ask what should be done about the problem and ask employees why they have proposed one solution instead of another. (This generally requires considering a range of solutions and collecting more evidence.)

Then they ask how they – manager and employees – will know when the problem has been solved, and engage one more time in dialogue on the best indicator.

 

Finally, after agreement is reached on the most appropriate measure of success, the employees set out to implement the solution.

 

For many of us that doesn’t sound much like respect for people. The manager after all doesn’t just say “I trust you to solve the problem because I respect you. Do it your way and get on with it.” And the manager isn’t a morale booster, always saying, “Great job!” Instead the manager challenges the employees every step of the way, asking for more thought, more facts, and more discussion, when the employees just want to implement their favored solution.

This back and forth process demonstrates how each person in the organization brings a perspective, and true problem solving means involving and engaging each individual. It’s not in making employees feel good, or in dodging tough issues, but rather actual, committed problem solving that enables each member of the organization to thrive. Indeed, as Mike Rother notes, “respect for people means that it’s disrespectful of people to not utilize their human capability to learn and to grow. That is, each person’s working day would ideally include some challenge, and each person is being taught a systematic way of meeting challenges.”

This is a much different view than is typically practiced in nursing homes. When problems occur, staff are oftentimes blamed for not following a policy (without regard to whether the policy is reasonable or even doable), counseled (to provide documentation that the facility acted on the problem) and scapegoated (often in a demoralizing way as other staff know it could happen to any of them).

Mark Graban shared a video in a recent post on respect for people that highlights a great example of how an organization shifted during an incident to exemplify a respectful problem solving process:

Creating an organization built on respect for people cannot happen overnight, and it can’t be done without the commitment of senior leadership. As we’ve noted in the past, organizations need to evaluate their entire process of problem solving, especially around incident investigations. Organizations must also stop penalizing employees for system failures due to lack of adequate resources, ineffective safety measures, and organizational policies that harm open communication and dialogue.

In Mark’s post, he notes the similarity between respect for people and just culture, and there is certainly a lot of overlap. Implementing a just culture is also a proven risk management strategy, as it leads to fewer errors and more complete problem solving. Examine this diagram from Outcome Engenuity:

jcdiagram

Respect for people holds that most errors are not caused recklessly or maliciously, but rather catch people up in a poorly designed or poorly functioning system, and, in order to rectify and prevent these errors from happening again, we must involve everyone in an organization in a thoughtful, purposeful journey of continuous improvement.

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Where is the Lean?

While information about lean healthcare is rapidly expanding, from books to conferences to blogs, long-term care predictably remains largely absent from the conversations and resources. This is unfortunate on many levels, as the field would not only benefit from embracing the core value of respect for all people, but it also has so many fewer resources than other sectors of healthcare already and desperately needs to utilize those resources more effectively and efficiently.

First, a look at a few reasons why LTC is once again lagging behind the healthcare industry:

1) Long-term care organizations invest less in innovation. This unfortunate reality may have as much to do with scale as interest, but the end result is stark. According to a recent survey, 64% of large healthcare organizations have a Chief Innovation Officer— a position virtually unheard of in long-term care organizations. Meanwhile, most acute care organizations have adopted EMRs, while– though it’s difficult to know exact market penetration (itself a sign of lack of interest)– LTC implementation of EMRs may be as low as 6% (2012), though likely closer to the 50-60% range (2013 in MD). Even the resources that are spent– for instance, LeadingAge’s Innovation Fund— rarely result in replicated projects.

2) Long-term care organizations, more so than others in healthcare, rely on rigid, hierarchical management philosophies and strong command and control styles of operations. This not only stifles line staff involvement in change operations, but creates a culture of doing only what you are told to do and an atmosphere where fear of standing out leads to conservative and reactive action.

3) Long-term care is governed by a punitive system of survey and certification that values documentation of work and the following of rigid policies and procedures over quality outcomes and resident satisfaction. Because many problems are buried deeply within the established system, it is much easier to rely on blaming of individuals rather than fixing systems. (Indeed, I’ve had many surveyors demand to see records of disciplinary action when errors have occurred despite evidence of systemic root causes.)

4) Metrics of performance are based largely on payment realities (census, PPDs, case mix) rather than satisfaction, effectiveness of operations or continued improvement. Additionally, trade organizations representing communities focus on eternal realities, like Medicaid funding shortfalls, rather than driving more efficient deployment of existing resources.

5) Many nursing homes exist in a perpetual state of near or semi crisis, fueled by unconscionably low wages and high turnover of line staff, insufficient labor, organization- and industry-wide financial strain, and near-constant threat of adverse regulatory and legal action.

 

In a recent article in the Gerontologist, Bishop et al notes:

Frontline service production in some traditional nursing homes exhibits many of the features of a classic “low road” enterprise, where management attempts to keep labor costs as low as possible through fragmented jobs and close supervision (Handel & Gittleman, 2004). Nursing home direct care jobs have few skill requirements, minimal selectivity in hiring, cursory initial orientation and on-the-job training, low wages and benefits, and supervision focused on completion of defined tasks (Bishop et al., 2008). Nursing assistants describe the work itself as repetitive, taxing, and demeaning. Workers are treated as unreliable and easily replaceable. High turnover justifies low on-the-job investment in workers’ skills, because internally trained workers are likely to leave for better opportunities.

Some culture-change adopters will point to their organizations’ success in overcoming some of these challenges. However, as Lopez (2006) noted in “Culture Change Management in Long-Term Care: A Shop-Floor View,”

resource limitations also forced management to adopt a series of punitive personnel policies that actively undercut the rhetoric and aims of culture change, turning culture change into a rhetorical device for shifting blame for care problems from structural resource limitations onto the attitudes of nursing aides.”

We’ve found this to be the case more often than not, with culture change-oriented organizations blissfully unaware of how their embrace of culture change principles is only skin-deep.

Where Lean Comes In

Building a lean culture offers many, connected benefits, from designing systems that support residents to valuing, respecting and trusting front-line staff to make improvements that bring benefits for everyone:

  • Creating or sustaining a culture of respect for people: Lean requires organizations to rethink the value of line staff, trusting those staff as both the experts and the agents of improvement.
  • Focusing on value: Lean thinking helps identify waste that is endemic in long-term care from poor inventory management to convoluted admission practices to absurd meal delivery systems.
  • Placing the resident first: Lean is, by nature, resident-centered. Using tools like VOC (voice of the customer), value stream mapping, and gemba visits, Lean helps identify areas where organizations are wasting resources or failing to meet needs.
  • QAPI-ready: Lean, especially when combined with six sigma, is a perfect method to drive QAPI programs, fully meeting CMS QAPI requirements and indeed building the very culture QAPI envisioned.
  • Operational edge: Lean helps organizations use the resources they already have to do better work. It leads to higher resident and staff satisfaction, higher census, reduced turnover time and better leveraging of human and capital resources.

The Affordable Care Act will continue to put pressure on long term care organizations to perform better, smarter, and more efficiently. Lean is the best way to make all of these things happen at once.

Ready to get started? So are we!