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An east-coast mid-size hospital passed its Joint Commission audit in December 2010. The lead surveyor had this to say in the exit interview: “The finding from an organization of your size is truly remarkable and incredible”. Consider the usual amount of work and stress during the weeks and months before the first Joint Commission surveyors visit. Now think about the future where you are really looking forward to the trip, and your chance to show up to the survey team. This is a very attainable goal. Take care of your processes and the Joint Commission Survey will take care of itself.
The best way to develop and maintain a process focus and process improvement focus in your hospital is by adopting Lean philosophies and principles. The Joint Commission itself has adopted Lean as its own process improvement methodology. For example, see the article “Don’t Just Talk the Talk: The Joint Commission Tackles Its Own Process with Lean and Six Sigma, Quality Progress, July 2009” on the Joint Commission website.
The following are five key areas identified by the Joint Commission’s observations in their survey, along with some recommendations from the Principal Lean Consultant assigned to this hospital.
Recommendation 1: Launch a strong visual workplace and 7S program
7S is a formal approach to organization and housekeeping, and is a cornerstone of the Lean approach. The surveyors were very vocal about the 7S program of the hospital. He openly commented that it was one of the better organized work environments he had seen in a while. Achieving this requires discipline and vision from within the ranks of leadership. At this particular hospital, the CEO made a departmental 7S project, as well as a well-organized office, part of the annual evaluation for all of the hospital’s leadership.
You should also focus on more than the traditional 5S program that most books are written about. The hospital adopted 7S to incorporate safety and security into every project.
Here’s how to be successful with your survey in this category, Train at least one or two 7S Mentors per department and unit. These individuals are not expected to do all the work, but are available to staff members when they undertake 7S projects.
Divide the hospital floor plan into a grid and allocate an area to each executive to round off for the 7S position. Make sure each executive is aware of projects that have been completed, so they can focus their attention on areas, and give them a quick checkup. Note to officers: If you walk through a messy area and you don’t say anything, you are ignoring the behavior. If you really want to do something different, wear scrubs, roll up your sleeves and help the 7S do the dirt. You are now in a moral position to point out the wrongdoing and demand its correction.
Recommendation 2: Implement tight supply management with Kanban
The administrator of perioperative services had his chance to shine by explaining the new and more efficient supply replenishment technique adopted by the hospital, the Kanban system. This hospital adopted Kanban as a methodology to replace the PAR system. The PAR level system is a bankrupt system that you should abandon as soon as you finish reading this article. The surveyors were also impressed with the organization of supply driven by Kanban management.
Here’s how to be successful with your survey in this category. It’s easy, just implement a Kanban replenishment system for all your supply points. This is one of those issues that you will have to fight with your content management department. Require that they replenish supplies to your unit using Kanban. You might think that as long as the supplies are there, you shouldn’t care how they get there. Stop and ask employees how often they have to call materials management, scrambling for supplies that should be there. Next ask yourself how reasonable is it to count each supply Every dayOf course, nobody does.
If you can’t get your content management team to step in 20th century, do a small pilot project with supplies that are not under their control. Then show the result and try again until you see the light.
Recommendation 3: Achieve a high level of employee engagement
One of the seemingly “trick” questions to the Director of Process Excellence was “And who does the actual project and implementation of all this Kaizen documented by your department?” His eyes lit up when the answer came back “Perfect staff. RNs, Techs, and all the appropriate stakeholders.”
Successful Lean enterprises are not about “a select few”, but about a culture of continuous improvement that involves everyone. An engaged workforce is the trademark of a mature Lean enterprise that will look to the long-term sustainability of its efforts.
Here’s how to be successful with your survey in this category, Train everyone, and continually remind each staff member about the importance of continuous improvement. Some hospitals hear about Lean and rush to hire some engineers to create their own “process excellence” department. We encourage you not to do this. Don’t even think about starting a “lean empire”.
Establish a department to manage and coordinate training and projects from each department and unit. this department should not Doing projects, as should be done by staff members in the units who identified the opportunity for improvement.
Recommendation 4: Understand and implement a Lean Management System
Joint Commission surveyors were very keen on tracking the results of Lean projects with the same metrics the hospital uses to track their performance, rather than creating new ones. It is very important that the fruits of your lean labor are visible on metrics such as patient discharge performance, patient satisfaction, physician satisfaction, employee satisfaction. This doesn’t mean you shouldn’t track other metrics like patient room changes, room changes per day, and OR suite changes, but it should improve overall hospital performance.
Here’s how to be successful with your survey in this category, If you haven’t already done so, tie your Lean efforts to metrics in existing dashboards. We know that every hospital has a management dashboard. We encourage you not to create a new one. Keep the dashboard up-to-date and have a mechanism in place to address deviations.
Implement local dashboards and use their physical location to hold daily 15-minute accountability meetings with department management. These native dashboards may or may not have the same metrics as the roll-up management dashboards.
Implement leader standard work. The closer you are to the distribution of value, the more standardized your work is. If you are a member of the management team, it does not mean that you do not have any standard tasks. An example is the checklist for the SPD manager to check the status of the department before going home at the end of the day.
Recommendation 5: Emphasize management’s commitment
How can you expect a member of hospital leadership to understand and commit to your hospital’s Lean initiative if they don’t understand the principles and tools? They won’t. The best case scenario is that some people will do their research by reading a few books (or perhaps Wikipedia), while the most likely scenario is that the majority will verbally and verbally respond to any requests for resources to complete projects and maintain process improvements. Will be bald
Here’s how to be successful with your survey in this category, Each member of the leadership team should attend a training session in which they get a chance to learn the principles and tools and practice on their own live projects.
Structure this training session as follows:
Day 1 AM: Lecture: Lean Basics and Kaizen. Create teams and identify 5 opportunities per team. One of these will be the PM project.
Day 1 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.
Day 2 AM: All teams report on the previous day’s projects. Lecture: Kanban and 7S. Select PM project on Kanban and/or 7S.
Day 2 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.
Day 3 AM: All teams report on the previous day’s projects. Lecture: Standard work. Select PM Project on Standard Tasks.
Day 3 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.
Day 4 AM: All teams report on the previous day’s projects. Lecture: Value Stream Mapping (VSM). The class gets together and chooses an area to map.
Day 4 PM: Class completes VSM of selected area.
Day 5 AM: Finish the VSM plan by adding all the opportunities identified during the mapping exercise to the continuous improvement database. End the morning by developing a plan for the value stream using simple goal deployment (Hoshin Kanari) tools such as the A3-T Team Charter and A3-X Chart.
Day 5 PM: Group presentation and celebration.
The comments, stories, suggestions above are not intended to be a comprehensive set of solutions. They are mainly a very successful Joint Commission survey and some of the lessons learned in the course of work carried out in the months preceding that survey. As you consider adopting Lean as your process improvement methodology, there are many other tools that are just as important as those mentioned here. These other equipments were also adopted by this hospital.
Now, it’s your turn to take action. The Joint Commission Survey doesn’t need to be a stressful event. Surveyors are looking for solid processes. Focus on your processes with a Lean perspective, and you can even look forward to your next survey.
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