Thailand's 'Lean' Hospitals

Bangkok Blog #6 – Friday, January 28, 2011

By Michele Jordan, VP Quality Improvement and Transformation, RVHS

There are five Thailand hospitals that participated in the first phase of the Lean demonstration project. We visited three of them this week. The other two are somewhat far from Bangkok so it was more cost-effective to have their representatives come and present to us.

We started by hearing two case study presentations by physician leaders at the Songklanagarind Hospital. Songklangarind is an 860 bed university teaching hospital with a very advanced Health Information System (HIS). They have made very impressive progress and have a really good grasp of how to apply Lean tools.

Dr. Rungsun Bhurayanantachai discussed how Lean was used to improve flow in the chemotherapy program. Problems included: long waits to get an available bed; patients turning up at hospital for admission without adequate prep, unnecessarily long lengths of stay, too much time spent on documentation and lack of a team approach. A few of the many Lean solutions they put in place to alleviate all of these problems included:

• Completing patient documentation and the medical order before admission- patient asked to do the medical condition checklist before they come to the hospital; order written and saved in the computer system to be activated when the patient is admitted; when patient arrives on day of admission they go directly to the ward.

• Implemented an “e-Kanban” system – pharmacy sends an alert through the computer system to let the ward know that the chemo drug is ready for pick up.

• Visual controls - a sticker is placed on the chemo bag to mark when there is 3 hours left for chemo administration; this gives the doctor 3 hours to complete the discharge summary; when the last bottle of chemo has been put up, the nurse puts a sign on the door to alert housekeeping that discharge will be today and when the patient leaves the room they are asked to turn the sign around to the other side which indicates that the room is ready to be cleaned.

The one-year results of the combination of these actions are:

• A reduction in length of stay for chemotherapy from 72.3 hours to 53 hours;

• An increase in bed utilization (i.e. the number of patients per bed per week) from 2.3 to 3.2;

• An increase in patient satisfaction scores from 3.2 to 4.6;

• Staff satisfaction increased for all indicators related to work speed, work process and team work.

Dr. Nipat Aui-aree, a Neuro-Opthamologist, discussed how load leveling principles were applied to the Bolulinum Eye Clinic. This clinic uses botox injections to treat people experiencing involuntary facial spasms. Before the Lean initiative, it was not unusual for patients to arrive at 8am even though the clinic did not open until 1pm. After applying Lean, turnaround has been reduced from 333 minutes (5.5 hours) to only 50 minutes. The number of steps in the process has been reduced from 15 to 11. Patient satisfaction is up from 2.77 out of 4 to 3.5 out of 4 and continues to rise.

Next we heard about the progress being made at the Suratthani Hospital, an 800-bed facility that sees 2,000 outpatients and 150 admissions per day. Dr. Suwicha Saringkarnpoonperm described the interesting approach the hospital is using to promote Lean. They are using the concept of “Dr. Lean”. They launched their process by visiting all departments of the hospital and using value stream mapping, spaghetti diagrams and genchi genbutsu to ‘diagnose’ problems. The 7 wastes are described as ‘symptoms’. The various Lean improvement tools are described as ‘drugs’ for treating the symptoms. They do 3 to 5 corporate projects per year. Their first corporate initiative was aimed at streamlining and leveling flow in the outpatient department. The improvements they implemented based on Lean Thinking included:

• Set up satellite units with general practices and well-trained nurses

• Set up call centre (a non-medical team) for management of the consulting system

• Set up an improved appointment management process and better communication with the GP and the patient

As a result, their outpatient process time has dropped from 5 hours to 2 hours and 40 minutes.

In the afternoon, we had a lengthy discussion with the international delegates on their learnings from the conference and each delegate had to describe one-specific action they will taken when they return home to advance Lean in their country. We also discussed how to get started with Lean. Professor Philip Choo and I shared the lessons we have learned in our individual hospitals.

Today was the final day of the conference. The week went by very quickly and it was somewhat sad to see it all come to an end. There was a lot of picture taking and exchanging of gifts. I gave each of the delegates a Rouge Valley pen and they were all very appreciative. We have all vowed to stay in touch so I’m looking forward to being part of this dynamic international network. Bangkok was a great host city for this conference and the organizers did an outstanding job.

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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Less waiting as a result of Lean around the world

Bangkok Blog#4 – Written on Wednesday, January 26, 2011 

By Michele Jordan, VP Quality Improvement and Transformation, RVHS

Sawadee Ka!  (That means ‘hello’ in Thai.  Actually Sawadee means hello and ‘ka’ is added because I’m a female).  The Thai people are so friendly and welcoming that I’m starting to feel like a local.  I can see why they call Thailand ‘the land of smiles’.

Day 3 of the conference was a fantastic experience.  We visited two hospitals to see their Lean improvements. First stop was the Saohai Hospital .  This is a small, rural hospital located about 90 minutes outside of Bangkok so we boarded our convoy of vans around 6:30am.  The hospital has 30 beds and an occupancy rate of 82%.  They serve an average of 280 outpatients daily.  There are 3 doctors, 2 dentists, 3 pharmacists, 48 nurses, 4 medical technicians and 100 supporting staff.  The hospital is a beautiful open-air facility that resembles a spa more than an institution.  This is not a far-fetched comparison because the hospital offers a blend of modern medicine and alternative medicine including massage, acupuncture, infrared sauna, music therapy, 'past life regression' and more.

As we disembarked from the van we were greeted by several hospital staff who presented each of us with a beautiful bracelet made of flowers.  We proceeded to a large auditorium where, to our surprise, we were treated to a local dance performance.  This was followed by a formal presentation on the hospital’s Lean initiatives.   Like all of the demonstration projects, Saohai began their Lean journey in mid/late 2008.  For a small facility they have made tremendous progress.  One of their projects focused on reducing the waiting time in their outpatient diabetes mellitus clinic.  They implemented visual management, a 6S, an A3 and a series of kaizen events.  The biggest change they put in place was to work with the 13 Primary Care Units (PCUs) in the community to reassign roles.  Before Lean, patients arrived at the hospital clinic very early in the morning so they could have their blood taken before seeing the doctor.  Now, patients are asked to go their local PCU the day before their clinic appointment to have their blood taken by the PCU.  For many patients this reduced the travel distance significantly and meant they didn’t have to come as early to their clinic appointment.  Skype is used for communication between the PCUs and the hospital clinic if needed.  When one considers that the 13 PCUs are completely separate from the hospital, this is a huge system integration achievement. Here are some of the results of this initiative:
·         Reduced total Turnaround time in the clinic from 258 min to 196 min (59% improvement)
·         Reduced waiting time for consultation with the doctor from 72 min to 30 min (58% improvement)
·         Increased patient satisfaction rate from 81% to 91%

They have also used Lean techniques to educate and empower patients to use self-care.  After lunch, more dancing and group picture we boarded the van for our second stop – the Saint Louis Hospital in Bangkok .  The two hospitals are in stark contrast to one another.

Saint Louis is a non-profit, private general hospital that is run by the Sisters of Saint Paul de Chartres.  The 500-bed facility is extremely modern and includes escalators, a new state of the art cardiac clinic and a large board room with computer terminals and microphones at every seat.

The hospital leadership is strongly committed to Lean.  They said that they chose Lean because it fits well with their vision – ‘to be a leader of hope in health care and health promotion’. Their first Lean project was focused on improving the cardiology outpatient care process.  Improvements include:  setting up a schedule to phone patients 3 days after their visit, streamlining the process for preparing the medical record, creating a handover sheet for the patient’s next clinic/service, using visual controls and standard work.  The biggest change was renovating the entire clinic based on Lean’s cell concept.  The cell concept requires co-locating all the services that are part of the patient’s value stream in one area to reduce walking for the patient/family. They also have several large screen monitors that display who and how many patients are waiting for each doctor at any given time.   These changes have resulted in a 23% reduction in the waiting time for doctor consultation (from 43 min to 33 min); a 20% reduction in total patient turnaround time (from 186 min to 149 min), improved patient satisfaction and improved staff satisfaction.

This hospital also used Lean to improve the non-emergency patients care process in the ED. An analysis of ED volumes by time of day found that the peak period is between 4pm to 10pm (just like at RVHS) so the team focused their efforts on this time period. They set up a new flow for patients who need only medical treatment and set up a new medical treatment room near the ED.  Patients who just require a wound dressing and are not first time patients are seen and treated by a nurse.  Cycle time and takt time calculations have been used to establish a process control board that lays out the timing for each step in the dressing change process. They introduced lots of visual management and standard work is posted in the department.  An x-ray alert card has been created to communicate when x-ray results are ready.  This hospital has empowered and trained nurses to function independently.  They can order x-rays before the doctor has seen the patient to reduce waiting time.  As a result of all these changes they have improved ED turnaround time by 69% - from 96 minutes to 30 minutes!

Saint Louis Hospital has a clear plan for where they wish to go with Lean.  They have a ‘Lean Council’ and invest in training. They are introducing a ‘unit optimization’ program whereby each unit will be asked to identify 3 priority problems they need to fix and they will pick one problem to work on.  There will be awards for the best performing teams.

All in all, this was a very interesting day. Both hospitals – one large and one small- have made very impressive progress and seem motivated to stick with Lean for the long term.

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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.

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Benefits of Lean similar at hospitals around the world

Bangkok Blog#2 – Written on Monday, January 24, 2011

Michele Jordan
VP Quality Improvement and Transformation

Today was the official start to the Seminar on Regional Sharing on Lean in Health Care.  There are about 25 participants sponsored by the Asian Productivity Organization (APO).  I am in awe of the rich diversity.  Participants represent 15 Asian countries:  Cambodia, China, India, Indonesia, Iran, Japan, Korea Malaysia, Mongolia, Nepal, Pakistan, Philippines, Singapore, Thailand and Vietnam.  Each country had to submit a ‘country paper’ describing their health care system and the status of Lean in the health care sector.  I have to read all 15 of them before the end of the week.

Most countries are in their infancy where Lean is concerned but they all see the potential for Lean to improve their health care systems and are anxious to learn more.  The health care challenges faced in Asia are similar to what we face in Canada – quality concerns (i.e. wanting to use more evidence-based practice; need to minimize adverse events), lack of standardization, patient satisfaction, meeting growing public expectations, trying to reduce length of stay and insufficient money to do all the things we want to do.

In Asia, many hospitals are run by doctors who serve as both practicing physicians and CEOs.  Most of the participants at the conference are doctors and all of the speakers today were doctors.

The first presenter was Dr. Anuwat Supachutikul, Chief Executive Officer, Healthcare Accreditation Institute who set the tone for the day by providing an Overview Application of Lean Thinking to Healthcare.  I think it is absolutely brilliant that Thailand’s Healthcare Accreditation Institute had the foresight to invest in Lean and sponsor demonstration projects in several hospitals.  They clearly see the link between Lean and quality!

Next  Dr. Cherdchai Nopmaneejumruslers, Assistant Dean in Quality Development, Siriraj Hospital gave an introduction to the theory of Lean touching on topics such as value vs waste,  the ‘House of Lean’ (similar to our ‘House of Rouge’), common  Lean tools, operational excellence, value stream mapping and visual management.  He also talked about error rates and adverse events.  Did you know that the rate of preventable deaths in hospitals is comparable to the error rate for airline baggage handlers? Dr. Cherdchai is a respirologist who trained in Canada at (U of T, McMaster and UHN). He is the only one I came across so far who can relate to the frigid temperatures in Canada in January.

The third speaker was Asst. Prof. Dr. Roengsak Leetanaporn, Director, Songklanagarind Hospital. He gave a series of small lectures on specific aspects of Lean thinking including: Benefits of Continuous Flow, Cycle Time, Takt Time, Cell Concept, Batching, Workload Leveling, Error Proofing and A3 problem solving. For each topic, he gave an example from his hospital.  His hospital currently has 300 Lean projects on the go of varying size and complexity!

One of the most interactive and enjoyable parts of the day was a Patient Simulation Exercise organized by Dr. Cherdchai and his team from Siriraj Hospital.  It was a fun exercise similar to ones we have used at RVHS but using Lego.  At the end of the exercise we showed how improving processes (without increasing staff or space) could lead to more patients being seen, better quality (reduced defects), improved cost-effectiveness and improved morale.  The results made true believers out of everyone in the room, especially the doctors.  (Look for this exercise at Rouge Valley in the coming months!!)

Two things struck me about Day 1 of the conference. First, the similarities in Lean implementation between the Thailand hospitals and Rouge Valley.  Like us, they are using 6S, A3 thinking, surgical safety checklists, standard order sets, value stream analysis and kaizen events. Their discharge planning whiteboards, complete with “EDD” look exactly like ours! They have even surpassed us in some areas. For example, they have implemented Kanban systems for inventory management.

The other thing that impressed me immensely is that we sat in a room for an entire day and talked about the benefits of Lean.  Yet no one ever mentioned cost-cutting – only improving quality and ‘making patients happier’. No matter what part of the world you live in, that is what Lean is all about. 

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From Rouge with Lean

Bangkok Blog#1 - Written on Sunday, Jan. 23, 2011
By Michele Jordan
VP Quality Improvement and Transformation, RVHS

When we started our Lean journey at RVHS who would thought that a mere two years later, people half way around the world would be interested in hearing our story.  Yet here I am in Bangkok where I’ve been invited to speak at the Seminar on Regional Sharing on Lean in Health Care.

So how did this come about?  In late November I received a telephone call from an individual who works in the Modernization Branch of the Ontario government. He said that he had heard me speak about Rouge Valley and Lean at a conference in Toronto several months prior.  The Ontario government has links with governments in many other countries and he has been doing some work with the Asian Productivity Organization (APO). The APO has existed for 50 years. They have promoted Lean in the manufacturing sector for many years but recently decided to explore the potential to deploy Lean widely in the service sector, including health care. He said the APO was holding a conference on Lean in hospitals and the organization would be interested in having a Canadian speaker.  He recommended me and with the support of our CEO, I was pleased to accept the invitation. All expenses are completely covered by the APO so there is no cost to the hospital for participating in this wonderful educational event. 

The conference runs from Monday, January 24th to Friday January 28th.  The first two days are a standard conference format with some of the best Lean experts in Asia scheduled to speak.  The next two days will consist of site visits to three hospitals in Bangkok that have been participating in Lean since 2008.  Lean was introduced into these hospitals as a demonstration project sponsored by Thailand’s hospital accreditation body and by the APO. I will have a chance to see the improvements these hospitals have made and contribute to an evaluation of their progress.  From the advanced reading materials I received it looks like all hospitals have made impressive progress.

I will speak at the conference on Tuesday afternoon and Thursday night. The week promises to be very busy and a great educational opportunity.  I will update this blog daily to ensure that interested individuals at Rouge can share in the learnings.  So stay tuned.

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