Yakima Valley Memorial Hospital
Yakima Valley Hospital gets Lean
The Situation
The kaizen experience at Yakima Valley Memorial Hospital (YVMH) has been one of continuous improvement and discovery.
- Four sessions of Lean Healthcare 101 have been delivered.
- Four major kaizen events have been performed.
- Some kaizen events spun off smaller projects that were pursued in parallel.
Lean Healthcare 101
This one-day introductory lecture and simulation was delivered on Sept 6, 7, 13 & 14, 2007 in the YVMH Auditorium. The program, expected to draw 40 participants, attracted 62 registered participants and many more audience members.
The lecture portion of the LH 101 covered the history and development of the Toyota Production System and profiled some of the current healthcare practices where TPS is being used. The program used PowerPoint, a quick hands-on demonstration of 5S principles and discussion of how Lean is applied at various hospitals.
Once the basic Lean principles had been defined, the rest of the day was spent with a hands-on simulation that put them in play. Developed by Impact Washington staffers Charles “Luke” Lukey and Linda Adams, the ‘Western Blood Lab’ simulation highlights the importance of Takt, pull and flow in a manufacturing environment. In this case, a blood sample is received for a Complete Blood Count.
In the first round, test tubes are received by a clerk, with the attached paperwork routed one way (Insurance, Accounting, Results Coordinator) while the blood sample is processed through Intake, Processing and Results. The results are matched up with the paperwork at the end and returned to the physician.
The players soon discovered that to be profitable, the process would have to be streamlined. The players also discovered the reality of Stat vs. Routine samples.
By examining the entire value stream, not just their specific departments, the players were encouraged to try new methods based on Lean principles.
After three rounds, the players discovered the value in maintaining customer focus throughout the process, in visualizing the process and placing the responsibility for change on the people closest to the work.
Feedback from the participants was excellent. The attendance lists provide another metric – as word spread of the simulation, the enrollment in LH 101 nearly doubled.
Kaizen Events
Kaizen #1: Phlebotomist Travel
The first kaizen event at Yakima Valley Memorial Hospital occurred October 23 -27, 2007.
A key player in modern healthcare is the phlebotomist. Phlebotomy is the act of collecting blood either for testing or transfusion. Depending on the patient’s condition, this task may need to be done a daily basis.
The physician decides a blood test is required, and notes the patients chart. The Unit Secretary enters the order into the computer. The order is received by laboratory and a phlebotomist is dispatched to draw the sample. Once taken, the phlebotomist labels the blood sample and sends it to the Lab via a vacuum tube system.
Once received, the Lab analyzes the sample and transmits the report to the physician.
Though it seems simple enough, this process can be scuttled by a number of variables, including:
- Physician ordering results on a Stat basis
- Unit Secretary entering Routine orders while Stat orders wait
- Phlebotomist off the floor to resupply cart or carry samples to Lab
The kaizen team identified the areas for improvement.
Improvements included:
- Defining areas with colored tape on the Unit Secretary’s desk for Routine and Stat orders – Physicians now place the chart in the desired area and the Unit Secretary’s priorities are clear.
- Stepping up an integration plan that put wireless handheld barcode readers and printers into wide phlebotomist use. By reducing or eliminating their dependence on paper instructions, phlebotomists are able to spend more value added time at their assigned areas.
- Outfitting phlebotomist’s carts with enough supplies to last at least half a shift. This eliminated the need to walk to the Lab supply room for needles, tubes and other supplies and reduced traffic on the vacuum system.
- Establishing a kanban method to the Laboratory Supply Room that insures adequate inventory of phlebotomist items.
RESULTS: Data showed YVMH physician ordering over 540,000 Complete Blood Counts in the previous 12 months. Estimates of wasted phlebotomist travel distance totaled 1500 feet per assignment.
A conservative estimate, calculated by cutting the CBC count to 250,000, still reveals a savings of 384 hours a year. Those 384 hours, conservatively priced at $25 an hour, saved $9600 annually.
Other time and distance savings were realized by streamlining the Laboratory Supply room, standardizing phlebotomist carts and the use of handheld devices.
During the course of this event, the team noted the waste of Motion and Transportation inside the Lab for future action. This became the starting point of the next kaizen event.
Kaizen #2: Lab Layout
The second event, in October 23 – 27, 2007, focused on the physical layout of the Yakima Valley Memorial Hospital layout.
Based on recurring problems, a new Current State Value Stream Map and issues raised by Kaizen #1, this team tackled the following issues:
- Reduce ‘inside the Lab’ travel distance for Complete Blood Counts (CBC’s)
- Reduce complexity at Lab Intake sorting process
- Reduce wastes in Diluent changeover process
- Envision a future floor layout that reduces waste of motion
The current layout requires the Lab Technician to walk 17’ 6” from the Tube Station to the first Complete Blood Count (CBC) process. Multiplied by 540,000 requests annually, that adds up to 351 miles.
Using a surplus magnetic white board, the team drew up a current lab floor layout and discovered a way to cut the amount of Motion waste for CBC’s in half.
Since the YVMH runs 24/7, the team was not able to access the actual Lab space to try out their ideas without disturbing the work flow. So they created a cardboard mockup of the lab in the Auditorium. Once the distances had been verified, they were able to prove out the saving that could be realized with a few simple changes.
Reducing complexity at the Lab Intake sorting process fell to the Lab Technician who knows it best, Jonathan Frazier. During the early morning rush hours in the Lab, it’s Jonathan’s job to get the samples to the correct destination. He admits it took a lot of practice to get the process down.
With the help of the team, he created a color coded method of routing incoming samples.
Diluent is a thinning agent used in blood analysis equipment. By reducing the viscosity of the sample material, results are achieved faster. But Diluent must be fresh to be effective.Yakima Valley Memorial Hospital receives 20 liter boxes of Diluent several times a month. Keeping the expiration dates straight is a challenge, as Diluent boxes are stored all over the Lab. At 40 lbs each, a 20 liter cardboard box of Diluent is not light. Lab workers may find themselves asking for help in changing the boxes out at the analyzers. The change over time can delay results.
RESULTS: After instruction in Kanban basics, the team developed a storage solution that keeps the Diluent boxes in one place, in plain view, and with a magnetic pointer showing which box is to be used next.
Based on this work, and the cardboard mock-up, the team realized that a more expensive ($10,000.00) change to the lab floor might result in enormous savings. They determined that by moving the Vacuum Tube Station about 20 feet, the hospital might avoid purchasing a $1 million conveyor system for a new chemical analyzer.
Kaizen #3: Recurring Outpatient Registration (ROR)
Good follow up is key to good healthcare. Rare is the patient who, once admitted to the hospital, is released with a clean bill of health, never to return.
After their initial admission, most patients are required to return to the hospital or outpatient clinic to check on treatment affectivity or to receive ongoing therapies. To eliminate the Processing waste of re-registering patients every time they appear at a Yakima Valley Memorial Hospital facility, ROR was developed. At their first admission, the patient’s registration record is held in a database and made available for future admissions. For the most part, this system works well. The problem stems from patients who visit YVMH facilities for multiple reasons. If a person were admitted with a foot injury in June, they would be treated and ROR’d to ease the registration process for Physical Therapy session to begin in August, after the foot was out of the cast.
But what if the patient appeared at YVMH with a persistent rash in July? And what if the rash turned out to be Methicillin-Resistant Staphylococcus Aureus (MRSA)? MRSA is difficult to treat and is a major player in nosocomial (hospital acquired) infections. It’s quite possible that a patient could present with one condition, be ROR’d in the registration system, and then present later with MRSA without anyone being alerted to their condition by existing Registration documents. Until it actually happened, the scenario made for interesting conversation among the Registration and Infection Control departments. Once it happened, these two departments requested and received permission to kaizen the ROR process. The initial kaizen event was performed November 13 – 15, 2007 and is part of a continuing effort.
This event had broad participation from the YVMH Registration, Outpatient and Infection Control departments. Based on interviews with all 15 different ‘Registering’ departments, and a Current State Value Stream Map, the team came to a conclusion. The fix required a better link between the patient’s Medical Registration Number (MRN) and the ROR database. This change allowed resistant micro-organism flags visible to everyone using the system. Now, when a patient is determined to have MRSA, that information is attached to their MRN, a ‘permanent’ record of the patient. That information can be reviewed by Infection Control and used by Registration personnel to better treat MRSA patients by scheduling their visits at the end of the workday, or some other kind of space segregation. The spread of MRSA is contained.
RESULTS: The ROR effort is ongoing. While it’s hard to put a dollar amount on a preventive effort, Infection Control is now receiving regular reports on MRSA patients, resulting in positive effects on public health.
Another problem surfaced right around the 25th of every month, when many departments ROR’d their patients for the next month. This increased activity slowed the entire YVMH computer system to the point where it could take over 20 minutes for the ER to get a simple printout. By creating a standard method of performing these updates, pressured was relieved on the system. Work is continuing in this area.
Kaizen #4: Arterial Blood Gas (ABG) sample collection
Much can be learned from a small sample of arterial blood, including how much oxygen a patient is getting. There are may variables to the ABG process:
- Most phlebotomists are not certified to draw arterial blood
- Respiratory Therapists (who are qualified) are in short supply
And one maddening constant:
- To insure accuracy, the arterial blood sample must not be over 10 minutes old
Getting the right person to the right patient to draw the sample was the first challenge. In some cases, ER personnel are summoned to various units simply for their practiced hand. A botched ABG draw can be life threatening.
The next hurdle appeared in the form of hand-held technology, a small device called an iStat. About the size of a vintage cell phone, an iStat can perform many of the tests that a lab can do, including ABG. Problem is, not many people know how to run an iStat machine. It requires a two-hour instruction course.
RESULTS: The first phase of this kaizen involved training more qualified ABG personnel and more qualified iStat operators. To that end, a training matrix was developed and is being pursued. Dollar estimates to follow. Eliminating reliance on the Lab and going completely over to the existing iStat equipment is estimated to save $68,000.00 annually.
Kaizen #5: Floor Collects
Stool, urine and sputum collection are rarely cited as reasons for entering the healthcare profession, but analysis of these materials is vital to healing. This kaizen event held January 28 – 31, 2008, was performed by a group of nurses and lab technologists. They discovered that each floor or ‘unit’ of the hospital has their own method for performing floor samples. Two members of the kaizen team focused their efforts on tissue collection in Surgery. Their work led to changes in the paperwork required to be filled out by nurses. The rest of the team resolved to create a simple, sustainable way to perform the ‘floor collect’ process.