Value-Stream Improvement for the Office and Services

Thanks to the several thousand Lean Thinkers who attended the Lean Enterprise Institute’s webinar “Value-Stream Improvement for the Office and Services” -- and emailed in more than 850 follow-up questions!

And thanks to our panelists from Hotel-Dieu Grace Hospital, Windsor, Ontario, Canada, for taking the time to answer a representative sample of questions.

John Coughlin
Senior Vice President,
Corporate Services,
Hôtel-Dieu Grace Hospital
Windsor, ON, Canada

• Executive lead for the hospital’s lean program
• Joined the hospital as Director of Human Services after practicing law
• Also held responsibility for Organizational Development, Health and Safety, Physical Plant, Renovations and New Construction, Information Services, and Health Records, as well as providing legal advice to the hospital

Q: Do you actually participate in the value-stream mapping discussions?

A: I do, but I intentionally try to keep my involvement low key. I tend to ask questions to provoke their thinking. I purposely do not provide answers. I attend because I want to demonstrate that senior management is interested in their efforts to improve their work because by improving their work (adding value to the customer, reducing the lead time, eliminating waste) the organization as a whole improves.

Q: How have you coordinated cross-functional conflicts where one project might try to shed nonvalue-added work that affects other areas?

A: We require that there be what we call a “service level agreement” with the other area. That means that those involved in a project that might impact another area must work with that other area in a supplier/customer relationship to work out an agreement with them that is acceptable to them. It may involve improving a hand-off such that the other area may absorb what becomes value-added work for them.

Q: How much time did you spend on this [emergency room] project? Percentage of your work day/week?

A: Initially, there was some scoping work, about one-half day, then the three day workshop. After the workshop, my work involved the board meetings, about one hour per week, then time spent being visible in the unit, seeing what was happening, discussing problems, reflecting and removing obstacles, probably about a day per week. As the project and the understanding of lean grew, it probably amounted to about a half day per week, but spread out over the week.

Q: Is your no-layoff policy a "must" to make lean successful? Is it sustainable in the long run?

A: I believe it is a must in order to get people involved and committed. The rule is actually “no one will lose a job because of LEAN.” So as we become leaner, we will increase our capacity and therefore our volume. We already have a high demand and are facing and ever increasing demand for our services. If necessary, we will re-assign people to other meaningful and satisfying work, but no one will lose a job because of LEAN. Yes, I do believe that this is sustainable.

Q: With regards to the four ground rules described for the events (respect, no job loss, span of control, and no additional resources), what is meant by "no additional resources"? Does this mean that the team doesn't get any resources outside of what they already have to make improvements, or does it mean that they can't propose ideas that just add more staff, etc.? Does this mean that the department doesn't get any replacement staff while the workshop is going on?

A: No additional resources means there will be no additions to the budgeted amounts for the departments/units, with the only exception being that people who attend the workshops and the initial review meetings will be paid at their straight time hourly rate out of separate funds set aside for the LEAN initiative. People who replace them are paid out of the department/unit budget and all improvement projects or tasks are to be worked on within their daily work or on their own time if they chose.

Q: We are just in the infancy stages of a lean journey. How did you go about "pulling" the leadership and medical staff into the process and getting them engaged?

A: We don’t “pull” them into the process. What we call “pull” is when they come to us asking for a LEAN process improvement project. Having said that, we do try to plant the seeds so that they see the value in such projects. Of course, the success of our ER project precipitated a lot of pull. Also, it helps if they see an example where LEAN has worked well elsewhere. It may vary depending on the individuals and the circumstances. As mentioned, we put some medical leaders
in touch with a former colleague in the United States who has done some very interesting lean improvement work.

Q: What is employees’ motivation to implement lean?

A: I think that the vast majority of people who work in healthcare are here for the patient. They were educated/trained in their particular area to help the patient and that is what they want to do. Our health system has inserted so much waste into the system that our healthcare workers’ ability to care for the patient is impeded. They want to remove the waste. They want to provide care and treatment more quickly and without error. They want patients to be more satisfied with the care they provide as individuals and we provide as an organization. In short, they want to be more satisfied with their work. They want to leave here at the end of the day feeling that they made a difference for the patient. I also think they want us to be a sustainable, long lasting employer, so that they have a sense of some job security.

Sarah Sasso
Coordinator Organizational Development
Hôtel-Dieu Grace Hospital
Windsor, ON, Canada

• 23 years hospital experience, including Neuro and ICU nursing, Clinical Education, Coordination of Critical Care Education, Organizational Development
• Responsibilities include training, coaching, and implementing lean concepts
• Currently supporting projects in Diagnostic Imaging and a Clinical Teaching Unit

Q: We have some issues with data quality. Do you rely on raw data or 80/20 'gut feel' data?

A: We try to work with whatever data we can obtain. We strive to collect accurate data; however there are times that we work with estimations.

Q: How are projects selected? Are the teams chartered to go find the projects or are the teams formed after the projects have been brought forward?

A: Our initial projects were departmentally focused and the project objectives were determined by the team. More recently, projects have been deployed from our senior management.

Q: How did you prioritize projects initially, and how do you do it now? Who makes the decisions to take on a new project?

A: The first year the major focus was on the Emergency Department. Over the second year department leaders submitted suggestions for projects to the senior team.

 Q: How do you manage the problem solving activities? Are people taken off their usual jobs and dedicated to a team?

A: Most of our departmental projects have part-time temporary facilitators assigned to keep the project on track. Staff members are taken off the job for the three-day workshop. Following the workshop, depending on the scope of the activities/ improvements staff may be given additional time to work on projects.

Q: Where would you focus first on delivering lean education -- to the middle management, supervisors, or operators?

A: Senior management and your value-stream owners need to have the knowledge to embrace the lean strategy. The middle managers, supervisors, and operators can obtain the education as you work through a project.

 Q: What visual tools were used to sustain improvements?

A: We have project display boards in each of the project areas that highlight the metrics and improvements. Additionally, standard work is posted in the areas. 

Q: How do you share best practice across the whole hospital?

A: We utilize our hospital newsletter, management, and facilitator meetings as vehicles for sharing practices. We also encourage departments to attend each other’s weekly board meetings.

Q: What is the best way to have employees buy into the lean process? How do you deal with employee resistance?

A: We try to engage as many employees as possible in a project. We find that resistance can be minimized if the following are addressed by leadership:  the project objective is clearly stated, people’s questions are addressed, and there is a clear set of expectations and follow-up on new processes. When resistance occurs we encourage the employee to articulate the problem. Most areas have a communication board that encourages staff to provide feedback on the project. Employees are encouraged to raise their concerns at the weekly board meetings. 

Q: Is there one single person responsible for each overall value stream?

A: We are working towards identifying the value streams in our organization and the responsible leader.

Q: How long has the hospital been at your lean journey? What types of system or structural changes have you made to ensure you're moving forward and the efforts are viewed as serious?

A: We have been on the lean journey for approximately two years. At the beginning of the journey a senior team member was appointed as the lean executive. Currently, we are identifying value streams within the organization and appointing leaders to manage the value streams. Members of the senior team are usually present at the 90-day project review meetings.

Q: How many employees do you have dedicated specifically for lean improvement projects?

A: One full-time hospital-wide lean facilitator and one part-time project facilitator in most of the project areas.

Nicki Schmidt
Lea(r)n Process Improvement Facilitator
Hôtel-Dieu Grace Hospital
Windsor, ON, Canada

• Worked as a Registered Nurse in hospital’s Emergency Room for 12 yrs.
• Chosen by colleagues to facilitate improvements identified by first ER value-stream mapping workshop
• Chosen as hospital-wide lean facilitator to spread lean initiative by improving processes throughout the hospital

Q: Were there any optimizations in the [emergency room] project that led to redeployment of employees? If yes, how was this was handled, especially communicating that this effort is not to eliminate jobs?

A: We did not redeploy any employees. Any time saving would allow for more time caring for patients, which was why we were doing this in the first place -- better patient care.
 
Q: Was advance training of lean needed with all the participants before the start of the [emergency room] project?

A: We did not receive any formal training prior to the workshop. We did receive some articles to read and had basic lean training during the workshop. With our subsequent workshops we have also provided articles, some training in the scoping sessions, and training in the workshop.

Q: How do you get frontline staff buy-in to the lean process when they feel they do a god job already?

A: Our staff does do a great job and we communicate that to them prior to the workshop and throughout. We stress the importance of being able to remove the frustrations in their day that interfere or make it difficult for them to do their jobs.
 
Q: Did you have all of the data readily available to populate the [emergency room] value-stream map If not, how hard was it to gather the data and how long did it take?

A: It was easy to obtain the high-level data, the in-process data was much more difficult. We relied on the expertise in the room to give us their best estimations for the data we didn’t have electronically. As we move to improve something within the value stream we will get more accurate data before and after, usually manually.

Q: We find that our extensive wait times in the ER seem to be caused by problems elsewhere in the hospital, for example, not enough beds so the patient can't be admitted and as a result waits in the ER. Did you encounter these types of issues? How were they reflected in the map and what did you do to resolve these "out of scope" factors?

A: We also have those issues, however, 85% of the people we see go home. We decided to concentrate on them as we had the most control over their processes. By improving their processes we were able to be more flexible in dealing with that 15 % that can tie up our beds. Through our value-stream mapping workshop we revealed enough problems in our own processes that if removed would allow for a large improvement. Since Our ER workshop we have been working with other value streams to remove our “out of scope” bottle necks.

 Q: How do you implement "customer pull" in a process driven by the arrival of "raw material" (patients) in the ER?

A: Due to having multiple responsibilities within the functioning of the department, the charge nurse was delivering patients in batches to beds. This caused a lot of frustration for everyone; often the physician and nurse would have open beds and a quiet time and then suddenly were scrambling to get the work done. We implemented a system in which the nurse for the dischargeable area pulls patients into their area as beds open up, it has allowed for them to level their own work and has also cut down on many steps.

Q:  How did you affect cultural change with the physician and nursing staff in the ER, and standardize their approaches? This has been one of our most challenging areas.

A: We have tried to stay away from the patient contact moment and practice initially and focused on the work processes, such as sequencing of work. There is enough that needs to be standardized in the way we organize our time to keep us busy for a while. I think as we improve those things, prove the value in standardizing that, and promote this type of culture, it will be much easier when we start looking at procedures, ordering practices etc.

Q: About your future-state mapping, how did you come up with a process that you felt would work better? Was it the result of brainstorming, or looking at what other successful hospitals did? And you had to go back to the drawing board once or twice?

A: We really just said what would this look like if you could change anything? What would make sense to the patient, how would it look getting rid of the nonvalue-added steps? Drawing the current-state map with such detail allowed us to see what we needed to do differently.

Q: Did you capture any traditional manufacturing value-stream mapping data such as cycle time and number of operators or did you just capture process steps?

For more information:
Mapping to See: A Value-Stream Improvement Kit for the Office and Services: Created by the Lean Enterprise Institute, the kit is the result of four years of development and testing. The kit helps you to train people in all parts of a value-stream improvement project, not just in value-stream mapping. 

Value-Stream Mapping for Offices and Services (formerly Business Process Value-Stream Mapping), Learn how to apply value-stream mapping to administrative, professional, and transactional activities. Through instruction, hands-on exercises, and case studies, you’ll learn how to document and analyze a current-state map of nonproduction value streams, then design and implement  future-state map.

Lean Enterprise Institute Webinar Library : To get first notice of all future free webinars and the answers to follow-up questions, make sure you are subscribed to our monthly e-letters. Using the Home tab drop-down menu, log in and check "Allow E-letters" near the bottom of the form.