Brian Belpanno is the industrial engineer for the Cohen Children’s Medical Centre in Long Island, New York State and Christopher A. Pinna is a certified improvement advisor and industrial engineer for the Improvement Sciences Team of the North Shore- LIJ Health System.
Here they have written about their approach to improving processes and standardising the staff techniques at a paediatric hospital.
- The challenges of implementing lean in a high volume treatment centre with limited space
- Investigation and encouraging staff involvement in bettering workplaces
Introduction: Cohen Children’s Medical Centre of New York
Cohen Children’s Medical Centre (CCMC) is a 202-bed children’s hospital which opened in 1983 as the New York metropolitan area’s only hospital designed exclusively for children. Today CCMC are the largest provider of paediatric health services in New York State. CCMC serves 1.8 million children in Brooklyn, Queens, Nassau and Suffolk counties in New York. CCMC is part of the North Shore-Long Island Jewish health system.
W. Edwards Deming famously stated “…most troubles and most possibilities for improvement add up to proportions something like this: 94% belong to the system (the responsibility of management), six percent are attributable to special causes.” Dr. Deming’s statement is masterfully typified by the system of operations in the Ambulatory Surgical Unit (ASU) and Paediatric Ambulatory Chemotherapy & Transfusion Centre (PACTC) of Cohen Children’s Medical Centre (CCMC). While both are distinctively different in terms of patient complexity and clinical specialisation, they are plagued by the same array of viruses; poor organisation, lack of standardised operations, and minimal inventory control. Such system practice ultimately results in excessive human and physical capital expenditure.
Division Administration wanted the issues resolved quickly using sound improvement science methodologies. Keeping this in mind they were presented with the concept of lean. It was explained that unlike six sigma which focuses on defect reduction, lean seeks to minimise waste in a system and is rapid in solutions deployment via the kaizen. To facilitate the solutions development the team followed the Lean+S3® solutions model. The model recommends for solutions to be simple, sustainable, and source driven (front line staff).
5S is a lean tool used for workplace organisation. 5S originated with the TPS. To use the tool, a team must follow the five simple words below (in order), and apply them to their workplace:
Sort – To Separate needed items from the un-needed items
Set (in Order) – To Arrange for easy access and visualisation
Shine – To ensure the area is cleaned and kept clean
Standardise – To ensure sort, set-in-order and shine are consistently implemented
Sustain – Hard-wire gains
In general terms, kanban is another tool originating from the TPS which focuses on inventory control through visual management. A basic kanban system requires each item to have a visible minimum and maximum inventory level. When stock reaches the min level it is reordered up to the maximum level.
5S along with visual management techniques, including kanban, are used extensively in lean manufacturing environments to eliminate waste by reducing time spent searching for items, avoiding stock outs, minimising downtime, and allowing managers to identify potential issues before they impact production.
These techniques can be translated to any process, in any industry, which relies on equipment and/or supplies/materials, including healthcare.
The CCMC ASU serves as a level two PACU for children receiving outpatient surgery. Each bay in the ASU contains limited storage space consisting of one 6 foot shelf. Each shelf holds the supplies required for the patients who will be brought to the bay throughout the day. Before going through the 5S process all the supplies were kept in one large bin with no dividers. Infrequently used items would become buried in the bin and large items would hide smaller items from sight. A time study showed, on average, it took a trained staff member 12.8 seconds to find an item in the bin. At times items could not be located in the bin and the nurse would have to retrieve supplies from the clean supply room delaying patient care.
Problem – PACTC
The Paediatric Ambulatory Chemotherapy and Transfusion Centre is a 15 bed outpatient setting that provides care to CCMC’s haematology and oncology paediatric population. The vast majority of PACTC patients receive chemotherapy, blood product transfusions and fluid hydration.
Available space in the PACTC comes at a premium. Patient treatment areas are not large and are separated via a curtain. In order to create a sense of ease and privacy most supplies and medical equipment, albeit a small supply cart, are not kept at the patient bedside. As a result equipment is placed in corridors or aisles within the unit, obstructing the free movement of staff and patients. Nursing staff would frequently remove the items and place them in areas prohibiting line of sight.
When administering care to patients the nursing staff would utilise a small four drawer bedside supply cart. Similar to the ASU, infrequently used items would become buried, large items would hide smaller items, and restocking would occur without performing an inventory assessment. The same principles held true for the clean supply room. It is important to mention product labelling was not present in either the bedside cart or the clean supply room. Analysis revealed an average time of 217 seconds to locate items in clean supply and 116 seconds in the bedside cart.
The Approach – IE Team
The first step in the transformation of the ASU & PACTC was to perform an evaluation of the area by the industrial engineering (IE) team. The IEs along with unit leadership, staff nurses, and materials management conducted a walkthrough of the area, identified opportunities for improvement and agreed on an approach to improve access to and availability of supplies. Baseline metrics were also collected via time and motion studies conducted by the IE Team
The structured approach began with education sessions for all staff in the ASU & PACTC. All staff participated in one of several 60 minute 5S learning sessions offered at varying times and days throughout the week. The learning session provided the team with the terminology and techniques used in the 5S process.
What we did – ASU
The Nurse Manager and the PCA, (the staff member whom was responsible for ensuring bedside stock) were provided with several options to replace the existing storage bins.
The final choice was a rectangular bin with custom dividers. Before the bins were placed into service a prototype was created with labels defining the location of all the supplies. The required quantity of each item was determined by asking nursing how many of each item they use per day and weighing that against the box quantity that was kept in the supply room. For example only a handful of adhesive strips are used during the day, far less than one box, but it would be very time consuming for the PCA to count out adhesive strips, so it made more sense for the entire box to be placed in the bin.
In addition to the new bins, 5S tape was placed on each shelf to outline the location of items too large to fit in the bin. A label was placed on the tape to identify which item fit into which location.
After one bay was complete the staff was given the chance to use the new setup for a 1 week trial period. After the trial period the staff provided recommendations to adjust the setup to better meet their needs. Changes included switching item locations in the bin to move taller items to the back. Once the tweaks were made the final product was reproduced in the remaining bays.
A post implementation time study showed, on average, it took a trained staff member 3.2 seconds to find an item in the bin. That represents an improvement of 75% from the original study. In addition, the number of bedside stock outs which caused unneeded trips to the supply room decreased to zero. It is estimated the ASU will save about $16,000 in labour costs which will be used to see more patients.
In order to sustain the supply organisation, regular audits are performed on the area by management.
What we did – PACTC
Post 5S training a team was assembled representing both nursing and administrative staff. They were tasked with thoroughly examining the bedside cart to determine supplies required for delivering patient care and configuration for ease of use. As part of the 5S methodology the staff gradually progressed through each of the S’s beginning with a red tag event. Once complete the cart was configured using both demarcation tape and dividers. The tape served as a visual guide for kanban inventory control while the dividers were utilised to keep products in designated locations. Labels were placed on both the outside drawer and on the upper right hand corner of each divider. Per infection control, the bedside carts need to be sanitised after each patient visit resulting in the development of a cleaning schedule to remain in compliance. Visual cues for maintaining appropriate inventory levels were posted in the clean supply room. A 5S Board was placed at the nurses’ station for sustainment.
Measurement – PACTC
As a result of this initiative the PACTC realised tremendous gains in efficiency and in cost reduction. The red tag event identified 12 items for removal from the bed side cart. The 12 products were high value items that expired. The cost of inventory on hand was estimated to be $2,486. The overall reduction in cost for the bedside carts was 35%. A time study post implementation also reviewed an increased efficiency of 60% when locating items. Similar to the ASU, bedside cart stock outs were brought to zero and regular audits performed by management to sustain inventory levels.
5S and visual management are an important foundation in any lean implementation. When used appropriately 5S has the potential to deliver tremendous results and reshape the how an organisation thinks about their workplace. Management buy-in together with staff education is imperative to ensuring success in any lean project. Both the ASU and PACT had strong leadership who believed in the techniques and dedicated resources to redesign the system. Their commitment allowed for solutions sustainment thus altering the culture of their work environment.