Section Sponsored by:

With 15 years at ThedaCare, based in Appleton, WI, Tracy Galione, MBA, RN, has developed a professional and personal investment in the success of the organization. Her tenure of service was interrupted only by a brief stint at an ICU manager in Chicago, and she returned to Northeastern Wisconsin from the Windy City in 2007 to become one of ThedaCare's lean facilitators.

For those unfamiliar with lean management practices, Galione did not take over as a dietary counselor; instead, she assisted nursing staff to cut the fat from daily processes that stand in the way of the most efficient practices and the best possible outcomes for patients.

Now the business unit manager of the med/surg unit, Galione continues to assist staff in employing lean principles in a developing community of empowered problem-solvers.

Photo Gallery

Going Lean in Healthcare

See how Appleton Medical Center improved processes.

Lean Principles Primer

Lean management principles are derived from the manufacturing industry, specifically from Toyota Motor Corporation, which espouses continuous improvement and respect for people. Sounds like a great idea to incorporate into healthcare, wouldn't you think? The Institute for Healthcare Improvement (IHI) agreed.

The IHI's 2005 White Paper Going Lean in Healthcare was based on expert presentations from the IHI Calls to Action Series. Among the experts was John Toussaint, MD, president and CEO at ThedaCare, who was integral to bringing lean management to the organization.

The white paper's executive summary briefly explained the purpose and goals of lean management as they would relate to healthcare:

"The Institute for Healthcare Improvement believes that lean principles can be - indeed, already are being - successfully applied to the delivery of health care. Lean thinking begins with driving out waste so that all work adds value and serves the customer's needs.

"Identifying value-added and non-value-added steps in every process is the beginning of the journey toward lean operations. In order for lean principles to take root, leaders must first work to create an organizational culture that is receptive to lean thinking. The commitment to lean must start at the very top of the organization, and all staff should be involved in helping to redesign processes to improve flow and reduce waste."

The commitment to the cause and foundational groundwork were in place when Galione returned to ThedaCare. In conjunction with senior leadership, she and a team of facilitators and operations managers dug in to complete the creation of the lean culture.

All in the Metrics

While there are a number of elements that go into a lean system of management, using measurable data to identify areas of improvement and define goals is at the heart of the process. As the med/surg unit prepared to move into a new patient tower in July 2010, Galione and the senior leadership team seized the excitement of a new environment to get staff focused on lean principles.

"One of the foundational tools we use is looking at distance traveled," Galione explained. "We had a rapid improvement event on the unit where we looked at shift report and used key metrics to guide us through our improvements. We looked at where the waste was in the work and then removed that waste from the work. The focus on waste reduction was also a focus on improving clinical quality."

Collapsing distance and time from shift report was identified as an area in need of improvement, Sheri Freymiller, BSN, RN, clinical lead on the med/surg unit, explained.

"In the old version of report we would tape record our report and touch base with the outgoing nurse," Freymiller said. There were two major issues with this process: 1) nurses would tape report when they had time to do so, which meant the recording was sometimes 1-2 hours old by shift change; and 2) if the incoming nurse became busy right away, she might not see a patient for an hour or so after the start of the shift.

This left patients unsure of who their nurse was, if the handoff had taken place and who was caring for them. By changing the standard work of the shift report, staff was able to shrink report time, improve the quality of the report  and add a customer service component so patients understand the handoff and are part of it.

"With our new report process, we update our [documentation] with pertinent information and the next shift reads that as soon as they come on," Freymiller said. "After a quick face-to-face, during which we can review the patient's chart to make sure all orders are completed, we actually go into the room together.

"The two nurses introduce each other so [the patient] knows the handoff is taking place and who is caring for them, and we touch base about what goals the patient wants to meet for the next shift," Freymiller continued. "We have a white board in every room, we update their goals on as the day progresses, and at each shift report we touch base about what their goals are for the day."

But how does more one-on-one interaction equate to less wasted time?

"When we would tape report there could be missed information, so after listening to report we'd have to go back to the nurses and get all the updates about what had changed," Freymiller explained. "Also, while working through the change we've developed standard work, so there are steps each person does, in order, to maintain consistency between patients and be able to keep moving through it smoothly."

In addition, as shift change approaches, nurses involve patients in the process.

"We begin to prep our patients in the last hour of a shift," Freymiller said. "We say, 'We're going to be in here introducing your new nurse, and we'll only be in here for a brief period of time. Is there anything I can get for you now before I leave?'"

According the Galione, the change in shift report has been a huge boon for customer satisfaction.

"As we did our leadership rounds with patients, they used to say they didn't think there was good communication, or that they didn't know who their nurse was," Galione said. "Now, if our shift change is at 7a.m., every RN has seen their patient and the patient knows who they are by 7:30."

There's also been an organizational benefit as a result of the new initiative.

"We've reduced our hours," Freymiller said. "The clinical leads and I have been working really hard on taking waste out of the work and collapsing distance so, when compared to January  2011,  we've taken a significant number of hours out of the work. We are able to show respect to the patients from a financial aspect but still maintain, if not improve, the quality of care."

The unit's sensei, or lean management coach, taught staff how to apply a basic tenet of lean, plan-do-study-act (PDSA) to the process. This enabled staff to work it, test it, experiment with it, and adjust the standard work based on staff input. Completing the PDSA cycle again and again over time ensures the best standard work for the current moment is being employed. "Through the PDAS cycle, we've been able to ensure month over month productivity," Freymiller added.

Galione concurred: "This is really staff-driven," she said. "For the leader, it's the discipline to make sure the standard work is observed as working, or that we're adjusting it to make it work."

Root-Cause Analysis

Another example of the lean process in action is a recent improvement to ThedaCare's order entry process.

"While working on a VHA patient safety initiative, we discovered we were missing patient orders," Galione recalled. "A physician writes orders and, for whatever reason, we were discovering the orders weren't always transcribed  -- there sometimes was a lag time of up to 48 hours."

And so the process began: a safety team was brought together, the team did a root cause analysis of the issue, and it was discovered not all staff were aware of the standard work related to order entry.

"The team decided the standard work doesn't work anymore," Galione explained. "We revised the standard work, educated and trained to it, and observed the standard. Our missed orders are down from approximately 12 a month to 1 or 0 a month."

Through process observation, future glitches in standard work can be avoided. Clinical leaders and unit managers are prepared to observe a set of standard work each day and evaluation their findings.

"Do we need to look at that piece of standard work and revise it, or is someone making a choice not to follow the standard work?" Galione explained. "[If the latter,] that is a coaching and mentoring opportunity to make sure that person understand s the rationale [behind the steps]."

Freymiller concluded that, "without knowing that piece, they might think skipping a step isn't a big deal; but understanding the reasons behind each step helps people be more invested in the work."

Designed for Lean

Since distance travelled is a main consideration when reducing waste, the med/surg unit is shaped in a triangle; between every about 2 patient rooms, there is an alcove with a computer for charting. Another time and motion saver is the supply cart, or patient server, in each patient room.

"The server contains almost everything a nurse needs daily to deliver care, and uses a visual cue system, called andon in lean terminology, to indicate when restocking is needed," Galione said. "When the nurse or nursing assistant removes something from the server, they flip a switch that signals inventory control to fill just the missing item. This saves inventory control from needing to go through everything and decide what's needed."

Each room features ceiling lifts, lighting as a safety feature to prevent falls, and a white board that serves as the communication tool physicians and staff use to communicate with patients and families.  Based on staff feedback, there's also a walker and commode in each room, which eliminates the need to locate these items when a patient requires them.

"When our building was designed, we used a lean process called 2P -- process preparation -- which looks at what's wrong with the current arrangement and what we need to do to prepare. Staff, patients and designers worked together to identify what was needed to decrease distance -- visual cues," Galione recalled.

"There are a lot of visual cues on the unit that help staff immediately know, for example, if a patient is at a fall risk or if there are orders that need to be transcribed. In addition, the unit design is open with lines of sight so team members can see what staff and patients are doing and where people might need help."

The Culture of Lean

Galione and Freymiller recognize the crucial role of organizational support in their unit's achievement in lean management.

"That's one thing any successful lean organization has, leaders from the top down that support the work," Galione said. "The hospital division has a management system we call the business performance system in which I have standard work as a manager. Each day Sheri and I go through a stat sheet of the overall operations of the unit, and then Sheri does the same type of meeting with her staff.

"All the things we're working on are visible, and each day we huddle with the staff, celebrate accomplishments and discuss opportunities. The staff drive that huddle with their recommendations for improvement."

The end result is a workplace where staff members' ideas are brought forward and they own the solutions, a world apart from traditional management models where staff might bring ideas or complaints which the manager then fixes.

"If, every time someone needed help clinically, the manager just fixed it, our staff would not grow professionally," Galione said. " It's about asking questions, stimulating their thoughts and helping them problem-solve in the work that really helps the staff become a community of problem solvers." 

Barbara Mercer is managing editor at ADVANCE.