By Dallas T. Sutton, Jr., CRES
Over the years, numerous initiatives have been put forth to instill quality, increase efficiency and productivity, and reduce day-to-day production costs. These tools, techniques, programs, and ideas generally come to us from the manufacturing industry and often have a hard time transitioning to the service delivery sector. Over the years, they’ve been known by different names—such as total quality management, continuous quality improvement, lean, and Six Sigma—but they all employ tools like define, measure, analyze, improve, and control (DMAIC); plan, do, study, act (PDSA); and voice of the customer (VOC)—to increase quality and reduce waste in any given process.
No doubt given the current economic environment, some of your organizations have at least entertained the idea of adopting some of these practices as a matter of self-preservation. Faced with reduction in reimbursement rates and increased capital investment costs, healthcare organizations are often left with few choices other than to cut expenses. Unfortunately, in the past, the easiest and quickest means of impacting the bottom line was to reduce staffing either through attrition, reduced hours or layoffs. The reality is that these cuts are often too deep, inconsequential, or made to the wrong areas, and they generally carry with them a long-lasting impact to morale that can lead to superstars seeking other opportunities.
Clinical Engineering, although very impactful to the organization’s operations, is in fact a cost center—not typically a revenue stream. Of course we can—and do—argue—the cost of not having us around with the powers that be, but it’s still pretty easy for them to inconsequentially cut a position or two from the so-called “basement-dwellers.” Whether you feel the pinch of an actual cut, lose a position due to attrition, or simply aren’t allowed to hire as your workload increases, most of us will experience “doing more with less” at some point. So how do you manage these situations? Most of us aren’t in a position to reduce the services we offer our respective organizations or charge more for them. That’s where process improvement comes in.
Write It Down
At this point, you’re probably thinking I’m going to talk about how important developing metrics and analyzing data are to your operations. Well, although metrics and data are important, that’s not where the rubber meets the road. As the title of this article implies, it’s all about process—specifically, the improvement of your existing processes. Here’s the thing, though: In order to improve a process, you must first write one down for everything you do. Without an existing process, you will find it nearly impossible to cut the so-called “fat” from an inefficient, cumbersome task.
When you add in the signature process, the work order documentation, and the physical disposal of the device, a routine process like the surplus of a device can take two hours. And when you do it 100 times a year, that’s 200 hours. What if you could streamline the process to one hour? How many additional PMs can you complete in the 100 hours you saved?
The documentation of an activity in the form of a process helps us to establish Standard Work—a principle that builds consistency into a process. (Remember: Variation in any process is a form of waste.) If your entire shop performs an initial inspection the same way, you’ll begin to get an idea of how long the process takes for a given device and where you spend the majority of your time. The funny thing is, with an empowered staff, they will tell you how long it takes and where they’re spending the majority of their time, and then they’ll start to make suggestions about how to reduce it.
Suggestions like moving a particular resource to reduce travel time (transportation and/or motion waste), the reordering of process steps, and the automation of tasks such as reports (overproduction waste) will all impact the amount of time spent completing a process. Yes, you can improve a process without writing it down, but how can you be sure everyone is following or even knows about the improvement? Think of it like a roadmap: You’re planning a trip you take routinely, but there’s a construction delay. So you look at a map to find alternative routes that you may not have known existed.
Just to clarify, yes—I’m suggesting that everything you do should be written down as a policy or process, including work order documentation, parts ordering and receiving, repairs/exchanges, and electrical safety, etc. Fortunately, these don’t have to be volumes of text documents; in our experience, this is not as effective as a simple flowchart. The use of a properly formatted flow chart—perhaps color-coded to differentiate between the individuals or departments performing a particular task—is much faster for your technical staff to employ than thumbing through a text document.
Electronic versions are even more appreciated—especially when they incorporate hyperlinks to external resources such as required forms or your computerized maintenance management system. The greatest advantage of a flowchart is that reads like a map so you can visualize the places you need to reroute to correct for inefficiency.
Educating the Staff
So, we’ve established that you need processes, that improvements in processes can increase efficiency, and that the technical staff plays a key role in the success of any process improvement initiative. But how do you go about engaging the staff? First and foremost is education. Technicians tend to be very logical people and, as such, will generally acknowledge the efficiency of one process over another when presented with facts.
But technicians are also people, and people are resistant to change. And even though they may acknowledge an efficiency improvement, they may not be receptive to changing their current workflow to implement it. As you may imagine, force-feeding change with a list of directives and corresponding consequences for failure isn’t necessarily the best approach. Instead, we have found that even the most hardened technicians will eventually come around with a series of baby steps.
The first step is formulating a training plan. Our department is fortunate to have a Lean Six Sigma Green Belt, some Yellow Belts, and a few individuals with varying levels of formal process improvement training to draw on. But if you don’t have these localized resources, don’t despair. Most organizations have a process improvement or Kiazen promotion office with Black Belts on staff who will be more than willing to guide you in your efforts. It’s important to mention that everyone in our department acquired their formalized training on their own self-initiative, self-study, and self-sacrifice, and they’ve been able to use this knowledge for the betterment of our team. That’s how powerful this can be once you start getting their buy-in.
One of the easiest places to start—and one with a louder bang for your buck—is the Waste Walk. This is essentially an observation tool that brings attention to areas of potential waste. In an effort to satisfy an Environment of Care requirement, we started with a simple department checklist with direct questions. Each week, a different staff member was responsible for completing the checklist, which enabled them to observe areas of the shop needing compliance with established policies (e.g., “boxes stacked inappropriately,” “exit pathways clear,” and “emergency signage visible.”)
After a couple of rotations through the shop, we added a little formal training during a department meeting to describe a Waste Walk. Using the Waste Wheel as a visual aid, we used the acronym “DOWNTIME” to represent the eight areas of waste identified in lean manufacturing: defects, overproduction, waiting, non-value-added processing, transportation, inventory, motion, and employee underutilization. Each letter included a brief explanation to help the staff identify these areas during their walk.
To exercise this newfound knowledge, each employee performed a scheduled Waste Walk with a member of the leadership team. Since employees were already accustomed to making critical observations within the shop, we simply focused their attention and added a resource to draw on as they familiarized themselves with the new process. This gave them the opportunity to observe day-to-day operations and identify what they saw as an improvement opportunity. At the end of the day, we ended up with dozens of observations of the same processes, with suggestions about how to improve them. The ideas were then fleshed out with a working group comprised of those who made the suggestions, so buy-in was almost a given. The takeaway is that the staff sees themselves as key contributors to the improvement and implementation of the processes that make us successful. It’s their program, and they have a sense of ownership in seeing it succeed.
Another term thrown around in conjunction with process improvement is “continuous.” We addressed this aspect by incorporating process improvement into each employee’s annual evaluation as a specific set of goals—essentially, having them randomly reevaluate each process throughout the year. The performance of numerous 5S, Waste Walks, and PDSA events by everyone in the shop gives department leadership a conduit to receive the data necessary to improve the various processes observed. The entire program is becoming second nature—and as the organization moves toward lean health care, our department will remain ahead of the power curve and serve as an example for others.
A little bit of recommended reading: Transforming Health Care by Charles Kenny, which shares the journey and some of the successes Seattle’s Virginia Mason Medical Center experienced in their pursuit of the perfect patient experience. Good luck, and remember: Process improvement is not an event; it’s a continual evolution of the way your do business.
Dallas T. Sutton, Jr., CRES, is supervisor of imaging engineering at WakeMed Health and Hospitals in Raleigh, NC