Lean Targeting Efficiency in Radiology
Lean services, Six Sigma™, and continuous process improvement: Call them what you will, techniques derived from the now-famous Toyota Production System (TPS) are growing in popularity as a means for health-care providers (and radiology, in particular) to reduce costs and improve efficiency and care—with minimal capital outlay. As Howard Fleishon, MD, a radiologist at John C. Lincoln Health Network (JCLHN), Phoenix, Arizona, explains, “Lean services are really built upon developing standardized workflow, and aspects of radiology are very amenable to that mindset. Radiologists need to be aware that this is being popularized in the health-care industry. With so many other specialties wanting to be involved in medical imaging, we need to put ourselves in the position where we are seen as the best group to manage medical imaging throughout the entire enterprise.” Fleishon believes that the implementation of lean tools can help—and he’s not alone. In Seattle, Washington, Virginia Mason Hospital & Medical Center (VMHMC) has pioneered the Virginia Mason Production System (VMPS), which has been used to apply continuous–process-improvement techniques to radiology for almost a decade. Seattle Children’s Hospital used lean techniques to refine the design of its new clinic and reduce construction costs, and imaging centers and hospital radiology departments alike are increasingly working with lean consultants to optimize processes while improving customer service. Ellen Ermer, MSE, senior performance engineer at JCLHN, says, “In continuous process improvement, you’re always asking, ‘What is the voice of the customer?’ In health care, that means the focus is the patient. Your goals should always be driven by what is best for patient care.” Adapting to Lean Methods Ermer stresses that the implementation of lean methods represents a cultural shift that should not be taken lightly by managers. “To be successful, you need the buy-in, constant support, and push from leaders,” she says. “They have to understand it to believe in it and allow it to become part of the way you do things at your organization. If you don’t have that buy-in, you’re only going to achieve process improvement in pockets, here and there.” Ermer further recommends that leaders choose terminology carefully when introducing lean processes to staff. “The lingo can be intimidating,” she notes. “Sometimes, the word lean alone can be misunderstood; when you say you’re going to go lean, people think it means you’re going to start laying off staff, and that’s not the focus at all.” Anne Daley, a senior consultant at Chi Solutions Inc, Ann Arbor, Michigan, adds that even the most basic lean concepts might be met with resistance from seasoned health-care employees who are accustomed to doing things a certain way. She uses the example of scheduling to demonstrate the challenge: “In lean services, you staff based on when the volume comes in, and not necessarily when people want to work,” she says. “That’s very hard for people to get accustomed to; a lot of health-care schedules are based on the eight-hour work shift—and health-care organizations like full-time workers, so they limit their ability to be flexible.” In 2002, VMHMC implemented its own production system, the VMPS. Lucy Glenn, MD, radiology-department chair, recalls how the organization made the transition from lean theory to lean reality, beginning with leaders. All members of the executive team became certified leaders in lean services, she says, “and all the vice presidents and chiefs went to Japan for two weeks’ training as well. Pretty soon, we had the next layer of managers go through the training, and then we started with week-long rapid–process-improvement workshops with staff.” Glenn reiterates that the implementation of lean services represents a culture shift, adding that it’s important to supply employees with sufficient motivation to embrace the change. “You have to create the urgency—tell people why,” she says. “We knew health-care reform was coming and that we were going to be facing economic challenges in terms of Medicare and insurers, while every year, we were seeing a 5% increase in expenses.” Craig Blackmore, MD, joined VMHMC’s radiology faculty three years ago, and he describes the VMPS as permeating the organization. “It’s not simply an overlay placed on the institution by the leaders,” he notes. “It’s really part of the culture. Everyone who’s hired by VMHMC is exposed to the VMPS as part of his or her orientation, and every staff member has at least some exposure to it and understanding of what it means. If you want to change something, you work through the VMPS. I’ve never been at any other center where everyone is so collaborative and standardized in approach to improving quality.” Lean Services and Radiology Blackmore characterizes lean methods as “a cultural shift from the way in which radiology is historically practiced. You’re taught, in medical school, to be an individual practitioner, whereas here, it’s a team model—we’re all collectively caring for the patient. I’m not just reading an MRI, I’m participating in the entire progression of care,” he says. He adds, however, that basic lean principles—maximizing efficiency, reducing costs, and focusing on the customer—strongly echo recent trends in imaging. “An important aspect of quality in radiology is not simply interpreting studies, but ensuring that the study you’re doing is the appropriate one for the patient,” he says. “That means seeing radiology as part of the global care process and being a radiologist who is a member of the team that’s caring for the patient.” Fleishon concurs. He recalls a rapid–process-improvement event in MRI at JCLHN that was part of a larger three-day lean initiative. Process changes made by the supervisor and two MRI technologists resulted in a huge reduction in room-turnaround time—from an average of 17.1 minutes to just 4.2 minutes. “These are the kinds of statistics that hospital administrators are hearing in the conferences they go to, and being able to show these improvements in radiology is critical,” he says. “Lean services also provide a common lexicon for hospital leaders, as well as for managers across all hospital departments. They can finally speak the same language.” Daley, who frequently consults on process-improvement projects for radiology, says that in her experience, movement and general workplace organization are major issues in most imaging departments and practices. “Anytime a person’s movement does not contribute to moving the care of a patient forward, it’s considered wasted activity,” she says. “Excessive movement slows down the process. You can see a lot of movement in imaging related to obtaining supplies for the various procedures; if the supplies are not easily accessible, this could result in wasted activity.” Glenn observes that, presented the right way, lean services are a natural fit for radiology. “For radiologists, lean services are just the scientific method,” she says. “You develop a hypothesis about what would make an improvement, test that hypothesis, and then measure again to assess whether you were correct. The method isn’t foreign—it makes sense on a basic level.” Successful lean-services implementations at VMHMC have included improving CT throughput and decreasing interruptions to radiologist workflow in the breast-imaging clinic. Glenn says that an easy way for imaging groups to apply lean methods is to identify issues on a modality-by-modality basis. “Identify things in each section that you want to improve, and make sure you touch on every area involved in the process—scheduling, image management, and so on,” she says. Focus on People Though the lexicon of lean services has a decidedly mechanical feel—production system, process improvement, rework—the method is people focused, with an emphasis on serving the customer better by meeting the employee’s needs better. Lean services work by empowering staff members to make rapid changes that will result in process improvements. “You work very closely with the staff,” Ermer says. “You work together to determine how to rid processes of waste and add as much value as possible—all while focusing on the patient.” Rapid–process-improvement events are among the most important tools used in lean method. These events (in TPS terms, kaizen workshops) bring staff—often, from cross-functional departments—together to maximize efficiency and reduce waste in processes. The key to making them successful and keeping employees engaged in them in the future is quick, visible follow-through action, Ermer says. “Most of the best ideas come from the people actually doing the work; they just don’t know how to implement them,” she says. “If you give them the tools and coach them, they just take off with phenomenal ideas. Anything that needs to be changed to improve a process—from reorganizing cabinets or updating software to creating or revamping policies—you do right then and there. You’re empowering people to get what they need from leaders, and when they see changes right away, of course, they feel great about that.” At Seattle Children’s Hospital, when Lisa Brandenburg, CAO, and Chuck Fritz, administrative director of radiology, joined together on the design committee for the hospital’s new outpatient clinic in Bellevue, Washington, they leveraged lean principles to create the most effective plan. “We set goals for ourselves, and those included improving both patients’ and providers’ experiences of being in the building,” Brandenburg says. “We studied the most common patient and provider flows to determine what services most needed to be adjacent to each other.” When the committee had a proposed design ready, its members built a to-scale cardboard model of the space and then invited staff to walk through it in simulated clinical scenarios—in essence, giving the layout a dry run. “When staff members told us something didn’t make sense or wouldn’t work for them, we moved it,” Fritz says. “We did several iterations of that to get the best design. Lean methods really drove us to have our staff working collaboratively.” Fleishon says that engaging staff with lean methods will yield ample dividends, in terms of employee enthusiasm and participation. “People are a critical part of this learning curve,” he says. “They are seen as a valuable resource. Showing that they’re participating in these types of changes improves the stability of their positions and provides them with valuable experience they can use throughout their careers.” Smarter Design Improving design is a key component of any organization’s lean makeover, whether it’s overall facility design or simply the way that a single workspace is organized. “Whenever I go into an imaging department and see boxes piled in hallways, I know there’s an opportunity there to do things better,” Daley says. “When things aren’t organized, it decreases efficiency and drains energy within the work environment.” In designing Seattle Children’s Hospital’s Bellevue Clinic and Surgery Center, Brandenburg, Fritz, and the team were faced with a tough imperative from leaders: Reduce costs by 25%, reduce space by 30%, and plan five years out when projecting capacity. “Our clinics are very dependent on services like radiology,” Fritz notes, “so we wanted to design, from the start, to support that.” Colocation rapidly became a watchword for the team, which strove to make as many spaces as possible as multifunctional as possible. For example, “In pediatric MRI, a lot of patients go under anesthesia, so we developed the radiology space to be contiguous to anesthesia and to the operating area—so there would be less waste of movement among the anesthesia and nursing staff,” Fritz says. Brandenburg adds that the line of sight offers a simple, intuitive way to determine whether a space will be as functional, for clinicians, as it should be. “The simplest way to understand how things are flowing in your department is to be able to see,” she says. “During the radiology mock-up testing, staff members who worked in radiology were coming in and asking whether they would be able to see certain things from where they were.” She continues, “We moved the planned main supply areas because the path was too convoluted. We also changed the relationship between the operating room and the recovery area so that we would have a single directional flow. The patient arrives on one side of the space, receives anesthesia (if necessary), receives the imaging study, and goes out a different exit, adjacent to the recovery space. The flow of that patient, through that area, was a huge design success.” Sustaining Change Many experts in lean services emphasize the continuous aspect of continuous process improvement. “To keep lean services alive, they have to be leader driven; leaders need to be involved and to hold people accountable,” Daley says. “Someone must check to ensure changes are sustained, and if they are not, there must be consequences. If the changes do not stick, it is generally a failure of leaders to keep the momentum going.” Ermer concurs. She says, “Leaders have to support lean services—to speak their language—and they have to be aware that they will encounter barriers as they move forward. That’s part of the process.” She adds that the biggest obstacle that organizations encounter in implementing lean services is dealing with the culture change inherent in the method. “Managing in a lean environment is a big adjustment because change is no longer top down; it’s bottom up,” she says. “Leaders’ role is to guide and direct the team through the changes the employees have suggested, but they really do have to trust and believe in what their staff has come up with first.” Glenn underscores the importance of trust, which she says is enforced, not undermined, by constant change. “Knowing that things are not set in stone, and that processes will continually evolve, makes it a little easier to be able to try,” she says. “You have to make sure your employees’ voices are heard to build trust in the process. The whole idea of lean services is that we don’t talk about change, we actually try it—and if it’s not working, then we just try again.” Fleishon is optimistic about the potential for continuous process improvement to enhance radiology’s role in overall care delivery. “The whole idea is to continue to experiment, to improve, and to change,” he says. “We currently have our MRI cycle time down to 4.2 minutes, but that doesn’t mean we’re done yet; next year, we may take a look again. These are statistics that have a serious impact, and that’s why hospital administrators are embracing this type of method.” Additional Reading - Getting Started $300,000 Leaner and 97% Happy Cat Vasko is associate editor of Radiology Business Journal and editor of ImagingBiz.com.