St. Louis Employs Lean/Six Sigma to Improve Clinical Productivity
September 26, 2010
Posted by chcablogadmin in : Cost Reduction, Innovation, Leadership
Many of you have employed innovative processes and business principles to improve efficiency and control costs. We’ve heard about Seattle and Miami’s efforts in this arena and now Lee Fetter shares St. Louis’ experience. These success stories are important for colleagues to hear; please keep sharing. And, be watching later this fall for CHCA’s Emerging Profiles Practice paper on this project. – Don
Lean/Six Sigma Processes Improve Clinical Productivity
by Lee F. Fetter, BJC Group President
President, St. Louis Children’s Hospital
Lee Fetter
For the past three years, St. Louis Children’s Hospital has focused heavily on improving enterprise-wide cost management and labor productivity. To do this, we employed Lean/Six Sigma process improvement methodologies as the infrastructure. We started our improvement initiatives four years ago, focusing initially on clinical quality and patient flow initiatives, including Blood Stream Infections (BSI) and Emergency Department Left Without Being Seen (LWBS). We significantly improved outcomes in these areas—BSIs in the NICU reduced by 75% and Emergency Department LWBS reduced by 40%. Given the success, we logically added labor productivity initiatives to our organizational project portfolio as a step toward improving cost management.
Patient and Employee Satisfaction Important Consideration in Process
Historical data analysis showed that we could gain the most from a labor productivity improvement initiative in Respiratory Care, Radiology, General Medicine/Surgery Inpatient Units and Food Service. For example, Respiratory Care was 6 FTEs over budget for 2007, and General Medicine and Surgery Inpatient Units were both 4 FTEs over budget for the same period. For Food Service, we targeted labor productivity improvement for our Dining On Call (room service program) implementation across inpatient units. Four FTEs were required to administer the program. These FTEs were unbudgeted and therefore would have to come from departmental efficiency savings.
Given the large negative labor productivity variance, the business case for working in these areas was obvious. However, we questioned how we could attain labor productivity improvement without compromising employee and patient satisfaction. We assumed that, if executed poorly, labor productivity initiatives would cause a negative impact on employee satisfaction. In essence, if you improve labor productivity without improving efficiency (i.e. eliminate waste and non-value-added activity), then you end up requiring staff to work harder to achieve the same results. In health care, it’s intuitive to believe that if employee satisfaction drops then patient satisfaction will be impacted as well. With this in mind, we decided that our success would not solely be defined by labor productivity improvement in any given area. Employee satisfaction and patient satisfaction must remain unchanged or, hopefully, enhanced.
In general, our labor productivity project teams have followed the standard Lean/Six Sigma approach to achieve improvement. This approach involves creating cross-functional teams, defining the process and associated inefficiency (waste or non-value-added activity) relative to workflow, removing the waste, implementing improvements and sustaining the gains.
Success Factors
Using our General Medicine Inpatient Unit as an example, we illustrate several critical success factors that were common across all of our labor productivity projects:
- Establish stakeholder buy-in – The project team included staff RNs, charge RNs, patient care associates (PCAs), physicians, financial analysts, a Lean Six/Sigma process improvement expert and the department director. Ad hoc members included representatives from Materials Management, Child Life, Food & Nutrition, Housekeeping and Pharmacy departments. For the primary stakeholders (RNs, physicians, PCAs), we conducted an analysis to understand their level of commitment to the project objective. From the results, we created specific engagement strategies for each stakeholder in order to honor what they wanted to get out of the project. For example, our physicians were concerned that any efficiency gains would reduce available time for teaching, so we made sure that improvements did not add time to their schedule, nor take time away from teaching. Staff RNs were concerned about having more work to do with fewer staff. We eased their concerns by reinforcing expectations for improvement while being very receptive to staff feedback throughout the project.
- Acknowledge and work to remove workflow barriers from the perspective of staff – Each primary stakeholder was involved in the design and execution of time and motion studies covering staff RN and PCA job duties. We had each stakeholder live a “day in the life” for each other. This allowed us to further cement buy-in and commitment to the project goal. It also helped garner an appreciation among the staff relative to how they affect each other’s workflow. For example, we discovered that our staff RNs and PCAs were spending an average of one hour per 12-hour shift looking for supplies and equipment and traveling anywhere from one to three miles in the course of their day. We implemented a department-wide workflow process and supplier-managed inventory system located on the unit that reduced wasted time waiting and searching for equipment and supplies.
- Provide easy-to-use staffing decision tracking tools – This was the most critical and beneficial success factor for our labor productivity projects. Existing staffing tools required manual data entry and were disorganized, time consuming to complete and not very informative (data rich but information poor). The existing tools also made it very difficult for the manager to collect information at the end of the month to explain why their department was over budget at the hospital monthly labor productivity meeting. Most importantly, the existing tools did not help promote establishing accountability and consistency among the charge RNs as it related to using the budgeted number of staff at any given time.
To remedy this problem, one of our Lean/Six Sigma consultants created an automated staffing decision tracking tool in Microsoft Excel to be used by the charge RNs. This tool records the factors (census, admissions, discharges, acuity, etc.) that go into deciding how many staff to use and converts the information into a variance to budget several times per day. The tool also documents verbatim comments about the staffing decision from the charge RNs. The data are presented in the form of pre-built graphs that update in real time and that answer questions such as “What is the department variance to budget month to date?”, “How does the variance change by day of week and time of day?” and “What are the top 10 causes for the variance?” The department manager and charge RNs react to this information and adjust staffing throughout the month to facilitate meeting the budget by the end of the month.
The staffing decision tracking tool is now used across the majority of our inpatient units and the ICUs as well as several ancillary areas, and has been a great success.
Improvement Returns $3 Million in Savings
To date, we have saved more than $3 million by implementing labor productivity improvement. Our Radiology, Respiratory Care, General Medicine/Surgery Inpatient Units, and Food Service departments are all performing at or better than budget with respect to labor variance. We were able to find efficiency gains in Food Service in the form of FTEs and have successfully deployed a Dining On Call program. For the most part, employee and patient satisfaction have remained unchanged and have actually improved in several departments. Only a few departments showed a reduction in employee satisfaction, but we understand the causes and are correcting issues accordingly.
Note: The staffing decision tracking tool is available to anyone interested in learning more; please contact Leroy Love, Lean/Six Sigma Program Director, at St. Louis Children’s Hospital, at lxl3121@bjc.org.
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