5 or 6 S: Having a Prepared Work Space to Get to Higher Reliability and More Joy on the Job

I remember Sr. Francis Martin imploring her fourth grade class to keep their desks neat because it was easier to get your work done if you could easily find the right book, your pen, and the correct notebook. I also remember being an intern in a delivery room that was poorly stocked and poorly organized trying to resuscitate a baby and feeling very frustrated.

In last week’s blog, I described a “messy” workspace (Nathan’s hot dog stand on the NJ Turnpike) and I also complimented the Maryland Emissions Inspection station in Owings Mills because it had no clutter and everything was organized to get the work done as efficiently as possible.

What tool might Sr. Francis Martin and the Team at the VEIP station at Owings Mills have used to make their workspace ready to get the job done? Ok, Sr. Francis Martin probably had not learned from the Toyota Production System while she was teaching me in grammar school but I bet the designers of the emissions inspection stations have heard of the 5S or 6S tool. 

When Safety is added the 6 S’s are:

1. Sort: eliminating everything not required for the work being performed.

2. Separate: efficiently placing and arranging equipment and material.

3. Shine: tidying and cleaning.

4. Standardize: standardizing and continually improving the previous three.

5. Sustain: establishing discipline in sustaining workplace organization.

6. Safety: creating a safe work environment.

I was thrilled this week to visit Unit 48 and to see how orderly the Unit was. Taking care of post-operative patients is hard work but it is made a bit easier if everything is in its place. Also, I was the Chief Medical Officer at Boston Medical Center when we had two fires on inpatient units and I was reminded how important it is to keep hallways clear in case patients need to be evacuated quickly.

How is it that Unit 48, under the guidance of their nurse manager Cele Gayhardt, RN, got so orderly? Well, the biggest reason is because the Unit 48 Team has begun to use the theory of 6S. But there is another reason, too.

We all know that our hospital was built awhile ago, before we had the need for so much stuff to take care of patients. I have been in many hospitals that lamented that there just wasn’t enough storage space on a unit for all the stuff so they just left it in the hallways. At GBMC, we are very fortunate to have a well-designed system for removing equipment from our units when we don’t need it and bringing it back when we do.

Under the leadership of Judie Kusiolek, our Director of Environmental Services and Patient Transportation, and Larry Stevenson,  Assistant Director of  Patient Transportation , we have a system that is designed, measured, and continually improved by empowered staff members. This system is focused on the people it is serving – both the patient and the staff and it is built on teamwork.

Here is how it works: when a piece of equipment (e.g. a bed, stretcher, IV pump) is not needed on a patient care unit, a staff member calls x6600 and gives this message to the dispatcher at the Transportation Hub. The time of the call is logged into the system and a transporter is sent to the Unit to get the piece of equipment. The transporter brings the equipment to the Hub where it is logged into the system and stored awaiting the next time that it is needed. When a piece of equipment is needed by a unit, they call the Hub and a transporter is dispatched to bring it to the floor. When the trip is completed, the transporter calls an automated number and logs in that he or she has completed the delivery.

Our Transport Team does a marvelous job managing this system. The Team completes over 12,000 trips per month, up from 3,000 six years ago! The average time from initial call to completion of a trip is under 15 minutes. I had the pleasure of spending some time this week with Murrell Hearns, a 10-year GBMC employee. Murrell explained the system to me and demonstrated the process for moving a piece of equipment or a patient. He showed me the importance of checking in with the staff when he arrives on the Unit and the care he takes in cleaning the stretcher when he is moving a sick patient. I watched and listened as Murrell treated every patient with kindness and respect. Murrell was the embodiment of our vision in action.  

Our transport system is a great system. But where might this system break down? In other words, what are its failure modes? Well, the biggest failure mode of this system we might call hoarding. This occurs when staff does not believe that Murrell and his colleagues can deliver on the promise that they will bring the equipment back quickly when it is needed. In this case, they don’t trust the system and they keep the equipment in a corridor or just outside of the unit and this then leads to clutter. In this instance, the staff do not believe that the system is reliable. In an unreliable system, everyone does what they think is best for them, in this case they hoard, thereby making the system even more unreliable.

Sr. Francis Martin and the folks at the Owings Mills Emission Testing facility know about the importance of having everything you need and only what you need and in its place. We are learning this too at GBMC through tools like the 6S and with the work of our wonderful Transport Team and our Hub! Thanks to everyone for helping to make our hospital more reliable to make it easier to get to our vision.

What can you do to make your workspace better organized?

Cancer Prevention Study

GBMC continues to be a learning organization and research is part of the way we can continue to make lives better.   As part of this effort, GBMC is partnering with the American Cancer Society on its landmark Cancer Prevention Study-3 (CPS-3), which seeks to enroll 300,000 people nationwide. On Friday, September 14 from 9:00 am-1:00 pm in the Civiletti Conference Center, enrollment will be available for anyone between 30 and 65 years old who has never been diagnosed with cancer (not including basal or squamous cell skin cancer) and is willing to make a long-term commitment which involves completing periodic follow-up surveys at home. Researchers hope this study will allow for a better understanding of the genetic, environmental and lifestyle factors that cause or prevent cancer, which will ultimately save lives. Anyone interested in participating can contact Laura Schein, Community Outreach Coordinator for the Sandra & Malcolm Berman Cancer Institute at GBMC, at 443.849.2037 or lschein@gbmc.org, or visit cps3baltimore.org

Good Leadership, Poor Leadership, Well Designed Systems and Random Behavior

I spend a lot of time thinking about how to move our health system faster towards its vision and I often reflect on incidents that happen to me in my life outside of GBMC and try to learn from them. I would like to share three episodes from my life over the past few days.

I do a lot of traveling on Southwest Airlines, I choose Southwest generally because they are the best at getting me to where I want to go safely and on time and they usually have the best price.  (This is the definition of value). They have been recognized historically for being very customer friendly, sharing GBMC’s value of respect, but I have been concerned lately that Southwest is losing its customer focus.

Last week I was waiting at the gate at BWI and sitting facing the Southwest Airlines counter and observed an employee who was talking on a cell phone obviously having a non-business related conversation. A woman came up to the counter, looking frantic standing in front of her, obviously trying to get the attention of this employee, who put her cell phone down.  The woman said, “Is this where Flight 396 is leaving from?” The employee turned, and pointed to the board that showed it indeed was the gate for flight 396, and the woman rushed off to get on the boarding line.  The Southwest employee then got back on her cell phone and complained to the person on the other end about the woman who asked if she was in the right place for her flight -  as if the customer was an annoyance.  Southwest, historically, has not operated like this. As I witnessed this I asked myself:  “What is the vision of Southwest Airlines?” “Does this employee know what Southwest’s vision is?” “Where is her supervisor? What would her supervisor say to her, if anything, if she witnessed this behavior?”

This past weekend, I was driving on the highway and I stopped at a rest stop to get something to eat. Ok, I must sheepishly admit I wanted a Nathan’s hot dog. The rest stop food concessions are all run by private companies. I was standing there waiting to order and there were several employees moving behind the counter and back and forth through a door that went to the kitchen. The line of customers was short, but it was taking a long time for anyone to get served. It wasn’t clear to me that there was any design to the work. It seemed almost that the people were working independent of each other and with no regard for meeting the needs of the people in line.  I then noticed two people who I later realized were the supervisors standing off to the side and chatting.  At one point they called one of the workers over and I heard them engage her in a conversation that was unrelated to the workflow. I finally ordered my hot dog and enjoyed it but the process to simply get something to eat was very challenging and by the time I left there was a long line of frustrated customers. Again, I started thinking: “Who is responsible for focusing on the customer in a business?” “What were the employees thinking?” “What was up with the two managers?” There did not appear to be a designed system for meeting the customers’ needs and leadership was truly lacking.

Compare these two situations with what I experienced earlier this week – taking my car for a required emissions test at the state facility in Owings Mills.

I looked online and saw that the wait time was just nine minutes and the on-line cameras validated that there were only a few customers waiting.  By the time I got there, there was actually zero wait, and I pulled in just behind a car that was leaving.  The young man took my sheet that I had received in the mail, checked my VIN number and hooked up the machine.  He asked how I wanted to pay, I swiped my card, I signed my name and he gave me the results sheet and credit card receipt, telling me I needed to come back in two years.  The whole thing took less than five minutes.

Not only was this system designed, but it looked like it had gone through multiple sequences of improvement to drive all the waste out of the process.  Through the eyes of this customer, the emissions inspection station performance surpassed my wildest expectation. There were no managers visible yet leadership was evident.

The characteristics that separated the two poorly functioning systems through the eyes of the customer from the one that delighted the customer were good leadership, true customer focus, and a well-designed system operated by a team of individuals who are empowered to make further changes to improve the system.

That is what we are striving for in our GBMC HealthCare System.

What can we do to get more customer-focused and design things better at GBMC? How can we use metrics better, get better teamwork, or make our staff more empowered?

Record Useful Information Only Once

One morning this week I was chatting with a few physicians in our medical staff lounge. “Did you see this?” one of them asked me. I looked to see that someone had tacked up a paper on the bulletin board that was from the “A Piece of My Mind” series in the Journal of the American Medical Association. The writer was lamenting the fact that since the implementation of electronic documentation, many clinicians, especially trainees, were abusing the “cut and paste” function to make their notes repetitive, lengthy, and unreadable. The doctors present with me in the lounge were unified in their belief that this new ability to repeat every fact about the patient in every note was making the record less usable.

I replied to my colleagues that I had seen and read the piece and that I had mixed feelings about it. While I agreed with the author’s basic lament that the regurgitation of information was not helpful, I was bothered by the tenor of his writing. You see, he was a teacher of the people whose work he was criticizing, and he also appeared to be blaming the creators of the electronic record for the fact that his work of patient care was becoming harder. I thought that he was in the “victim box”. He was going to write about this problem so that some great power would fix it. He did not appear to be willing to take any action to help improve the situation.

In 1994, which was also a time when people were talking about healthcare reform, Dr. Donald Berwick, then the President of the Institute for Healthcare Improvement, wrote a paper in the same journal in which he proposed 11 worthy aims of clinician-led reform. One of the aims was recording only useful information only once. Dr. Berwick realized then, and it is ever-more true today, that in an electronic record it is pure waste to record the same thing twice because in a database after the first recording the information can be displayed whenever it is needed. He knew that not only is the second recording of the same data element wasteful, but it creates an opportunity for error like we have with multiple allergy or medication lists in the paper record.

In both the paper and the electronic record there is the potential of waste and patient safety issues. Most of us believe that the benefit that the electronic record gives in making the information available everywhere trumps its failings. But I am in agreement with the author of the JAMA piece that we have to stay vigilant to prevent the creation of a record that is less usable because of its repetitiveness.

But what about Dr. Berwick’s notion of clinician-led reform? At GBMC, our clinicians are making marvelous improvements from doing standard work in the use of central lines to stop infections, to creating order sets to increase the use of evidence-based strategies, to extending office hours, and yes to implementing electronic records so that what the primary care team knows about a patient is available to the ED Team when the patient needs help. Our doctors and nurses haven’t looked to a higher power to make these improvements so we shouldn’t be looking to some higher power to change the recording habits of our junior or not-so-junior colleagues. We should get in action to record only useful information only once! This is my problem with the JAMA piece. Why did the author write the piece before he had sat down with his team to change their work?

What actions might you take to make the patient’s medical record more usable and safer?

A GBMC Icon is Recuperating

Git Merryman, the indomitable “Mr. G” of the Volunteer Auxiliary, who has greeted and helped so many of our patients from his post in our main blood drawing station, has been recuperating from a significant illness at GBMC. Git told me that it would be ok for me to mention this fact in the blog. He is very grateful for the wonderful care he has received from our physicians, nurses, therapists, housekeepers, food service workers, and others. We are grateful for all that he has given us and I can’t wait to see him back at his post! 

Standard Work, Daily Measurement, and Keeping our Patients Safe from Infections

It has been a number of years since healthcare organizations started working on hand hygiene as a way to reduce the spread of infections. We have made some progress, but many outsiders have gotten frustrated with our inability to “just do it” and make “washing in” and “washing out” the rule.

At GBMC, we have improved significantly in this area but we still have defect rates of around 20 percent. It is hard to get closer to perfection on this one. But we have gotten beyond lamenting the reasons why we can’t do it. As I said in the blog a few weeks ago, we are getting better at improvement.

We know that winning organizations don’t rely on hard work and good intentions alone. They design systems to get to the results that they want. Once the system is designed by the people in it, they follow the design… it’s called standard work. Standard work gets us to much higher reliability and much lower defect rates. Teams that create standard work use daily measurement to see how well the design is operating and to reinforce its use. Brief daily conversations about how the design is working also help people see further improvements.

Eileen Skaarer, RN, the Clinical Manager on Unit 45, has been leading her team in the creation of a design to get to better hand cleansing results. They have been doing a quick audit, by a different staff member daily, of their hand hygiene compliance. Twice each day, 5 observations are done of people entering and exiting a room and the results are put on a graph at the nursing station. When a team member is observed to have not washed on the way in or out, the auditor reminds the person of the necessity of washing. The person who did not wash gives the reason why they did not and this is also recorded for learning on a Pareto chart. When the person did wash in and wash out, he or she is congratulated.  At the daily huddle, the previous day’s results are reviewed with the team. 

The chart below shows the Unit’s improvement over time when measured by a secret observer.  You can see that in July, the nursing defect rate was zero!

Eileen and her team will keep working on the design until they get to perfection but what about the rest of GBMC HealthCare? Well, we have to get better at spread. In healthcare we are not as good as we need to be at testing a change, finding out that it works in the test area, and then spreading it to other units. The Hand Hygiene Team is working to spread the Unit 45 design and daily metric to our other inpatient units. I can’t wait to see our improvement over the next few months!

What ideas do you have to help us spread standard work faster?

Vacation: A time to reflect

I have been on vacation this week. I am enjoying sleeping a bit later than usual, reading, going to the beach, and relaxing. I am also enjoying some extra time with my family and friends that I don’t see too often. We are going to three concerts this week. I will show my age by saying that we will see Joe Walsh and Steve Miller. Lyle Lovett is popular with a broader age range, though.

Vacation is also a great time to reflect (Maybe it’s the trance-like state you can get into at the beach staring out at the waves). I am reflecting about how lucky I am and how great it is to be part of a team at our health system that is working to build on what is right in American healthcare and is in action to change what is not. We are watching the Olympics. I marvel at how talented these athletes are and the pain they feel when they make human errors and see their dreams slipping away (U.S. Men’s gymnastics) and how elated they are when they achieve the dream (Missy Franklin).

While watching the Olympics I am also watching the commercials. Hospital advertising is big on television here (somewhat bigger than it is in Baltimore). Last night, I saw a number of glitzy (and undoubtedly very expensive) ads for a hospital company touting “the new care.” I was wondering what was new? Did the patients see it as better? Did it lead to better health for individuals or the community than the “old” care? Or at least did the patients perceive that it was easier for them to navigate, especially when they had chronic disease? We should be desperate as a nation to make care less costly. Was this “new care” less costly? Did the people that worked for this company, especially the doctors and nurses believe that the “new care” made it easier for them to treat patients so that they could realize more joy in their practice?

But I realize that it is easy to be critical. I am reflecting on my own behavior and wondering what could I do better to move GBMC towards better health, better care, lower cost and more joy, faster? The email keeps coming. Yesterday I got an email from Sue Bowen, our Nursing Director of Maternal and Child Health. Sue had done a marvelous job developing a solution for parents of babies in the NICU who may stay with us for months. Our daily parking fee can add up if you are coming and going multiple times in a day over many weeks. Now, after a number of days, parents will get a parking card and will not have to pay. I subsequently got a thank you email for the work of Sue and her team from a father who was grateful that we now had a parking solution for him. He will now have a somewhat better experience of his baby’s care at lower cost to him.

I have been reflecting on last week’s learning for our new Performance Improvement Masters and the great work they did in mapping the value streams for patients from the time they entered the Emergency Department until they got to a bed on an inpatient unit, for patients moving from the PACU to an inpatient bed, and for a patient getting discharged from the hospital. Right now, we have people working very, very hard in processes that don’t work as well as they might. I am very excited about the redesigning that is happening in these critical areas. I am reading the book: Leading the Lean Enterprise Transformation by George Koenigsaecker, so that I can be a better participant in these efforts.

Oh well, a few more days of sun and then back to work.