A medium-sized hospital on the East Coast passed the Joint Commission audit in December 2010 with great success. The lead surveyor had this to say in the final interview: “Very few finds from an organization of its size are truly remarkable and incredible.” First consider the typical amount of work and stress during the weeks and months leading up to a visit from Joint Commission surveyors. Now think about a future where you really look forward to the visit and the chance to show off to the surveying team. This is a very achievable 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 a focus on process improvement in your hospital is to embrace the Lean philosophy and principles. The Joint Commission itself has adopted Lean as its own process improvement methodology. For example, see the article “Don’t Just Talk: Joint Commission Tackles Its Own Processes with Lean and Six Sigma, Quality Progress, July 2009” on the Joint Commission website.
Below are the five critical areas identified by the Joint Commission’s comments in their survey, along with some recommendations from the lead Lean consultant assigned to this hospital.
Recommendation 1: Launch a Strong Visual Workplace and 7S Program
7S is a formal approach to organizing and cleaning, and is a cornerstone of the Lean approach. The surveyors were very vocal about the hospital’s 7S program. They openly commented that this was one of the best organized work environments they had seen in a while. To achieve this requires discipline and vision on the part of the leaders. At this particular hospital, the CEO conducted a 7S departmental project, in addition to a well-organized office, as part of the annual evaluation of all hospital leaders.
It should also focus on something other than the traditional 5S program that most books write about. This hospital adopted 7S, to include security and protection for each project.
Here’s how to stand out in your survey in this category.. Train at least one or two 7S mentors per department and unit. These people are not supposed to do all the work, but rather be available to staff members when they embark on 7S projects.
Divide the hospital floor plan into a grid and assign an area to each executive to round up the 7S status. Make sure each executive is aware of the projects that have been completed, so they can poke their heads into the areas and quickly review them. Note to Executives: If you walk through a cluttered area and say nothing, you are tolerating the behavior. If you really want to make a difference, put on a scrub gown, roll up your sleeves, and help 7S clean up the mess. Now you have the morals to point out the mess and demand its rectification.
Recommendation 2: implement strict supply management with Kanban
The Perioperative Services Administrator had the opportunity to shine by explaining the new and much more efficient replenishment technique adopted by the hospital, the Kanban system. This hospital adopted Kanban as the methodology to replace the PAR system. The PAR level system is a failed methodology that you should abandon as soon as you finish reading this article. Surveyors were also impressed by the organization of supplies, driven by the Kanban leadership.
Here’s how to stand out in your survey in this category. This one is simple, just implement the Kanban replenishment system for all your supply points. This is one of those problems that you will have to grapple with with your Materials Management department. Demand that they replenish supplies to your unit using Kanban. You may think that as long as the supplies are there, you shouldn’t care how they get there. Stop and ask the staff how often they have to call materials management, yelling for supplies that should be there. Then ask yourself how rational it is to count each supply daily, which of course, nobody does.
If you can’t get your materials management team into the 20th century, run a small pilot project with supplies that are not under your control. Then display the results and try again until they see the light.
Recommendation 3: achieve a high level of staff involvement
One of the seemingly “tricky” questions for the Director of Process Excellence was “and who documents the actual project and implementation of all these Kaizens documented by their department?” His eyes lit up when the answer came: “Well, staff, of course. Registered nurses, technicians, and all the right stakeholders.”
Successful Lean companies are not about “the select few,” but about a culture of continuous improvement that involves everyone. An engaged staff is the trademark of a mature Lean company that will see the long-term sustainability of its efforts.
Here’s how to stand out in your survey in this category.. Train everyone and relentlessly remind all staff members of the importance of continuous improvement. Some hospitals hear about Lean and want to rush to hire engineers to create their own “Process Excellence” department. We recommend that you DO NOT do this. Don’t even think about starting a “Lean Empire”.
Create a department to manage and coordinate training and projects for each department and unit. This department should not do the projects, since they must be carried out by the personnel of the units that identified the opportunity for improvement.
Recommendation 4: understand and implement a lean management system
The Joint Commission surveyors were very interested in tracking the results of Lean projects with the same metrics the hospital uses to track its performance, rather than creating new ones. It is very important that the fruits of your Lean work are reflected in metrics such as patient performance at discharge, patient satisfaction, doctor satisfaction, staff satisfaction. This doesn’t mean that you shouldn’t keep track of other metrics such as patient room change, shortage per day, and OR room change, but this should lead to an improvement in overall hospital performance.
Here’s how to stand out in your survey in this category.. If you haven’t already, link your Lean efforts to your existing dashboard metrics. All hospitals that we know of have an administration panel. We recommend that you do not create a new one. Keep the dashboard up to date and have a methodology to address deviations.
Deploy local dashboards and use your physical location to hold a daily 15-minute accountability meeting with department management. These local dashboards may or may not have the same metrics as the cumulative dashboard.
Implement the standard work of the leader. The closer you are to delivering value, the more standardized your work will be. If you are a member of the management team, it does not mean that you do not have a standard job. An example is a checklist at the end of the day for the SPD Manager to check the status of the department every day before going home.
Recommendation 5: Insist on Management Commitment
How do you expect a member of hospital leadership to understand and engage with your hospital’s Lean initiative if they don’t understand the principles and tools? They will not. The best case scenario is that some will do their own research by reading a few books (or maybe Wikipedia), while the most likely scenario is that most will pay attention and resist any request for resources to complete projects and maintain improvements in the works. processes.
Here’s how to stand out in your survey in this category.. All members of the leadership team should attend a training session where they have the opportunity to learn the principles and tools and put them into practice in their own live projects.
Structure this training session as follows:
Day 1 AM: Talk: Lean basics and Kaizen. Form teams and identify 5 opportunities per team. One of them 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. Reading: Kanban and 7S. Select PM project in 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. Reading: Standard work. Select PM Project under Standard Job.
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. Read: Value Stream Mapping (VSM). The class stays together and selects an area to map.
Day 4 PM: The class completes a VSM of the selected area.
Day 5 AM: Finalize VSM planning by aggregating all opportunities identified during the mapping exercise into a continuous improvement database. Close out the morning by developing a plan for the flow of value using simple goal implementation tools (Hoshin Kanri), such as A3-T Team Charter and A3-X Chart.
Day 5 PM: Presentation and group celebration.
The comments, stories, and suggestions above are not intended to be a complete set of solutions. They are primarily some lessons learned during a very successful Joint Commission survey and work in the months leading up to that survey. If you are considering adapting Lean as your process improvement methodology, there are many other tools that are just as important as those mentioned here. These other tools were also adopted by this hospital.
Now it is your turn to act. The Joint Commission survey does not have to be a stressful event. Surveyors look for robust processes. Focus on your processes with a Lean perspective, and you can even wait for your next survey.