Friday, January 28, 2011

Lean requires leadership buy in, support

 Bangkok Blog#5 – Written on Thursday, January 27, 2011 
By Michele Jordan, VP Quality Improvement and Transformation, RVHS

Today was another busy but very educational day.  Again we set off from the hotel before 7am for a hospital site visit.  (One thing I’ve learned is that you don’t want to get stuck in Bangkok’s rush hour traffic.)

We spent the day at the Siriraj Hospital. Before describing some of the hospital’s many, many Lean initiatives you cannot talk about Siriraj without mentioning two things – its size and its history. Siriraj is huge!  It is a sprawling ‘empire’ consisting of 74 buildings.  They have about 3,000 beds, 1200 physicians, approximately 8,000 nurses and about 4,000 other staff. They have 24 medical departments, a cardiac centre, the medical education technology centre and 8 paramedical schools. Their enormous medical library is the most amazing any of us on the tour had ever seen.  The hospital is currently in the midst of a major redevelopment project that would see them expand even further on their current site as they seek to become the Centre of Excellence in southeast Asia. Siriraj Hospital is situated right on river and the views from most buildings are spectacular.  Because of the traffic situation, water ambulances are common.

In terms of its rich history, Siriraj is the oldest hospital in Thailand.  It was established in 1888. The official opening was presided over by King Chulalongkorn. The hospital is named after his young son, Prince Siriraj, who died of dysentery while the hospital was being built. The hospital has always received strong support from Thailand’s royal family.  The father of the current King was a Harvard-educated doctor and his original medical school notebooks are displayed in the hospital library.  Interestingly, Siriraj is currently the residence of the  much beloved King of Thailand.  He is in his 80s and has been hospitalized there for over a year.  Each day hundreds of loyal subjects and busloads of school children come to the hospital to pray for the King. You can imagine the implications that having a King as an inpatient has for hospital security!

My day at Siriraj went something like this – official picture taking in the courtyard, formal presentation by hospital leaders on their Lean journey, two hour press conference for myself and the two experts from Singapore, lunch, tours of a few departments (the oncology unit, the trauma unit, the lactation clinic and postpartum area), discussion of what we saw, dinner with select hospital leaders and finally after-dinner presentations by Dr. Choo and myself on Lean leadership.  We left the hospital at 9pm!

Several things impressed me about Siriraj:
·         Their leadership team is strongly committed to Lean.  This was demonstrated in many ways including the promotion of our visit as part of the Lean in Healthcare conference (there were posters everywhere), the arrangement of a press conference just to talk about Lean, and at least four physician leaders gave us detailed presentations on Lean initiatives in which they are involved.  Like RVHS, Siriraj has a strategic plan-on-the-page and a strong set of core values that they have actually set to music.
·         Understanding of Lean is spreading throughout the hospital and improvement ideas have tended to come from the frontline.  On every unit we visited, nurses in traditional white dresses, white shoes and starched white caps were able to explain in detail the Lean principles and tools that they have chosen to apply to their areas – everything from process control boards, to Kanban systems, to visual management and some of the best 6S results I have ever seen.  One nurse was asked where she learned the Lean techniques she has applied to reorganize her supply room. She replied that she learned these techniques from her own research using books and the internet.
·         They have incredible discipline. Like everywhere else, staff  report that changing mindsets was tough at first but having made changes they are able to sustain them.  Everything is kept up-to-date. When asked whether they have trouble getting nurses to maintain the discharge board, one head nurse replied ‘no, it is what we do as nurses’.
·         Their data collection is rigorous.  For every Lean initiative they presented, there was good baseline and future state data. They have solid statistics to back up their successes.
·         They are fostering a healthy workplace for innovation.  They have recently launched a program called ‘R2R’(Routine to Research).  They are de-mystifying the concept of research as something only for scholars and showing how research and innovation can be part of everyone’s role.  This was very evident in the breastfeeding program.  Breastfeeding is a centre of excellence for Siriraj and they are leaders in breastfeeding research.  Five nurses and 2 practical nurses see 60 mothers a day in the lactation clinic.  Nurses that work in this program are encouraged to be very creative.  They walked us through the various types of breastfeeding-friendly hospital gowns they have designed, the breastfeeding pillows they have created for both comfort and infection control purposes, the Madonna jacket (unofficially known as the “Lady Gaga Jacket” -- see the photo) they designed to teach expecting mothers how to breastfeed and the application of Lean principles to create a reliable system for storage of breastmilk.  
·         They have invested in internal resources to support their Lean implementation.  They have a “Utilization Management/Lean Office” that is very similar to our TMO.  Six nurses spend 80% of their time in this Office coaching staff on how to make improvements.  They also offer 3 levels Lean training – Lean Basic, Lean Supervisor and Lean Manager.

Siriraj has too many Lean initiatives underway to describe each one but here are a few highlights of their achievements:
·         By reorganizing their model of nursing care using Lean’s cell concept, they have reduced average length of stay from 8 days to 4 or 5 days in less than 2 years.  It took 6 months to implement the changes.  Nurses meet once per week to discuss how to improve quality.
·         They have done a lot of work on end of shift handover rounds and reduced the time this takes from 45-60 minutes down to 15-30 minutes.  Now, nurses and doctors round together.  Nursing satisfaction has increased significantly for all indicators tracked including a sense of harmony on the team and feeling respected by doctors.
·         Patient satisfaction has increased to 95%!
·         They have used Lean in their clinics and reduced outpatient turnaround time by 35%.  They actually see 65% of outpatients earlier than their booked appointment time.
·         Given the vast size of the Siriraj campus, transporting lab specimens is time consuming.  By applying Lean to this process they reduced the staff required from 13 people to 1 person! Of course, there were no layoffs, and the staff time saved has simply been redeployed to meet other important patient needs.

The amount of positive change this large institution has been able to achieve in a relatively short period of time is quite phenomenal.  

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