eSSee Consulting

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.

by Sean Carey

How Scrum Can Improve Stand-Up Meetings

In many nursing homes, one of the first items on every day’s agenda is the daily stand-up. Some communities have these quick check-ins down: organized, routine, and efficient, highlighting admissions, needed assessments, and any issues from the 24-hour report. I’ve also seen these meeting sprawl for 20 or 30 minutes, or divert into side discussions that occupy everyone’s time to solve an issue between two departments.

Scrum is a software development methodology based on a flexible, iterative model of team collaboration. When implemented effectively, scrum has helped software developers improve productivity by up to 500% by staying focused on the most important challenges, collaborating as a team, and responding quickly to new challenges. You might think scrum is a funny word for a development strategy, but it has a very important background. In rugby, scrum is the way that play is restarted, similar to a tip-off in basketball. Instead of being an individual effort, like the tip-off, however, scrum involves the whole team working together to gain control of the ball. While individual strength and skill is important, no team can compete effectively unless they work flawlessly together. The same idea has been applied to software teams. (And has something to teach healthcare teams.)

While there is a lot to scrum, one of the key features is the daily stand-up meeting that involves each person on a cross-functional development team meeting briefly. What’s involved in the daily scrum meeting?

All members come to the meeting prepared. In post-acute care, this means accurate information about admissions, discharges, assessments and any resident issues.
The meeting starts at the same time each day. Some communities do this well already, though oftentimes I’ve seen meetings delayed until the administrator or DNS arrives. In a scrum daily meeting, the meeting starts, even if someone isn’t present, and it’s the missing person’s responsibility to learn the information missed.
The meeting is timeboxed. Timeboxing is an important project management tool that limits a meeting to a specific length of time. This keeps issues focused and means that issues are prioritized or dealt with in separate (and usually more efficient) ways. For a 100- 150 resident nursing community, 15 minutes should be plenty of time for a stand-up.
Anyone is welcome to attend (though typically only involved core roles speak), and meetings are oftentimes held in hallways or corridors to emphasize the open component. This is an important commitment to openness that allows other staff to stay abreast of development efforts throughout the organization. With an open stand-up, CNAs, cooks, and housekeepers could see some of the nursing home “machinery” that is critical to the day-to-day work.
The meeting consists of each core person answering three questions: what did I do yesterday? what am I planning to do today? Am I experiencing any stumbling blocks or impediments to getting my work done? The “team lead” (scrum master) documents any challenges, but no discussion occurs during the stand-up. Rather, issues are dealt with in smaller groups, involving only those people required to resolve the situation.

What I love most about the scrum meeting is the focus on what’s happening and whether there are any roadblocks to people completing their work. This approach fits well with Lean philosophy (along with servant leadership, which is eminently vogue in LTC right now), and emphases the role of the team lead as an enabler: their primary role is to ensure the team is able to do its work. This person is responsible to remove identified roadblocks, keep the team on track, and prevent outside distractions (in long-term care, think regulatory issues, corporate initiatives not related to the work, interpersonal challenges between department staff, etc.) from interfering with completing necessary work.

Streamlining and focusing stand-up can have a big impact on staff’s ability to work effectively throughout the day. If your stand-up wanders, or doesn’t focus on the most crucial info to share, look at whether the scrum daily meeting concepts above might be able to improve this crucial meeting.

by Sean Carey

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.

by Sean Carey

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.

by Sean Carey