Presenting Lean - Insights from Singapore hospitals and RVHS

Bangkok Blog#3 – Written on Tuesday, January 25, 2011

Michele Jordan
VP Quality Improvement and Transformation

The format for Day 2 of Seminar on Regional Sharing on Lean in Health Care was a little different than Day 1.  The first day was a small gathering of about 25 invited delegates from across Asia. The second day was open to the public, and there were approximately 250 participants from health care organizations in the local Bangkok area.

There was a poster exhibit with several hospitals promoting their Lean achievements. A range of clinical areas were covered, including cardiac outpatient care processes, chemotherapy for solid organ tumours, breastfeeding and surgery. I was very impressed with the work of a team at the King Chulilongkorn hospital that applied Lean to improve operating room utilization for colorectal surgery. In just one year, this hospital was able to increase OR utilization from 44% to 74% while also reducing cancellations from 35% to 10%!

The formal part of the conference included two speakers that I had been anxiously looking forward to meeting – Dr. Kelvin Loh and Dr. Philip Choo.

Dr. Kelvin Loh (MBBS, MBA) is the CEO of the Mount Elizabeth Hospital in Singapore. After introducing Lean in some Singapore hospitals, he was hired as the expert consultant for the five-hospital Lean demonstration project in Thailand. He talked about value stream mapping, sustaining the gains and spread. Dr. Loh promotes the concept of a combined ‘top down and bottom up approach’ to Lean implementation – something worth exploring at RVHS. Value stream mapping in Asia is more oriented to patient groups or specific procedures (e.g. total knee replacement). The VSM crosses clinical departments. Dr. Loh recommends that hospitals have three levels of coordination to support their value stream improvements:

1. A ‘VSM Driver’ who owns the value stream that is being mapped -- i.e. someone who owns total knee replacement;
2. A few process owners for departments that fall within the value stream (e.g. nursing, physiotherapy); and 
3. An overall coordinating Lean Council or Quality Council that keeps track of all VSM projects and prioritizes activity.

Dr. Loh ended his talk with a few thought provoking ideas to use Lean to improve processes. For example, load leveling in outpatient clinics to eliminate what he calls the ‘morning tsunami’ that is so common in hospital clinics. He suggests scheduling non-fasting patients and those who live close to the hospital in the afternoon rather than have everyone come in the morning. He also challenged the notion of all departments running clinics and rounding at the same time. He suggests a model where clinic space could be shared between medicine and orthopaedics for example. Orthopaedics would use the clinic in the morning and do their inpatient rounding in the afternoon. Medicine would use the clinic in the afternoon and do their inpatient rounding in the morning. He also recommended one-stop shopping for patients, much like what we have introduced in our pre-op clinics at RVHS.

Professor Philip Choo, CEO of the Tan Tock Seng Hospital in Singapore is one of the strongest advocates for Lean I have ever met. He has visited hospitals all over the world, learning how they have approached Lean. His presentation was entitled, “Leadership at all levels - A Key Success Factor in Lean Paradigm Shift”. He shared some very insightful information on requirements for cultural change, the role of leadership and seven competencies of effective leaders. I had the opportunity to speak with Dr. Choo over lunch, where we compared notes on our efforts to improve the discharge process and our application of EDD (estimated date of discharge). In Dr. Choo’s hospital, the most responsible physician must identify the EDD for the patient within 24 hours of admission. They must communicate it to the clinical team and write it on the discharge whiteboard on the unit. If a doctor does not identify an EDD, Dr. Choo is informed and takes it up with the chief of the department and the individual doctor – he notes that no doctor want to experience this twice.  His hospital has made dozens of excellent improvements since starting Lean in 2007. For example, cataract surgery is now booked as a 15-minute procedure with high-quality outcomes.

After hearing Drs. Loh and Choo speak, I told them how excellent their presentations were and that my only complaint was that they had left very little for me to say because our tools and strategies are so similar.

In the afternoon, I had the opportunity to give a one-hour presentation. I covered:

• Lean in the Canadian health care system
• Application of Lean at RVHS
• Lessons Learned

Everyone at RVHS should be very proud to know how impressed the audience was with our progress. I have already had two people express interest in coming to Canada to visit us.

The day ended with a two-hour panel discussion in which I took part. We focused on how to sustain Lean and took questions from the audience.

Read Bangkok Blog#1 

Read Bangkok Blog#2