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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.

 

 

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.