Healthcare – Agile/Lean principles and practices in a hospital

Since my last posting on this subject, with a family member having been admitted into care in a hospital I was able to talk to other health professionals who particpated in the care giving. For the past two weeks, I had the impression of smooth flow and wait free attendance of the care and auxiliary staff who needed to attend to the care and recovery of one particular patient at hand. I had sampled the Nursing staff who were explicitly assigned on the ward when sharing what I had observed.

However, its quite possible I have conveyed skewed perspective given that my daily visits were around the same time window between 12:00 – 2:30 pm. I managed to discuss my observation of what appeared to be smooth flow in providing the patient with the daily need in care (medicine, meals, clean up, exercise etc.) with couple of the aides who came in to give a breathing treatment, this usually lasting no more then 15 minutes. It works out that not every task, even the medical treatment task, appears on the ward Scrum board that I had previously mentioned. In fact he pointed out that his daily orders of which patients to attend to for this particular type of treatment appeared from the Pharmacy. He pointed out, more often than appearances had so far led me to believe, there would be a bottle neck in the patients room with number of care personal trying to serve one need or another. This resulted in waiting and lining up similar to the lines we see at a grocery check out – his exact statement. Fortunately they have some slack and really freedom to coordinate their time, so often they’d go to a nearest patient needing service and return there after. No doubt there are others who may not be permanent fixtures to the ward but do provide service to it that have similar experience, and waiting may not be the only waste that they see or experience.

Clearly, there is room for improvement that can lead to better coordination and collaboration amongst all the care providers. In the ideal case having a shared and common information system, Scrum or Kanban board at the ward level would be of great value. In general I would say at the strategic level there is an opportunity to work at the ward level with all the care staff to Train, Map and Check on Lean principles, in particular their role in helping identify and eliminate waste. I say do this at the ward level, as in my mind this is the effort of a team. Though I consider Lean thinking to take place a many levels, including individual, role as well as team based. I like the following example 8 Wastes with Healthcare examples (ref: Lean Healthcare Exchange).

I also realize that the Paul Levy‘s recent blog Kaizen Corner – standardized work was in part addressing this and the opportunity of better coordination in order to deliver value to the customer. His blog is aptly called Running a Hospital.

Healthcare – Agile/Lean principles and Kanban practices in a hospital ward

Well its been a week since I last reported, with the family member admitted to the ward and the use of a Scrum board, this was a white board by Nurses station on the floor and it indicated assigned stories that a team of Nurses were working on.

Week 2, things have moved along. They have just today started using the electronic board, more along the lines of the Kanban board that ER. There appeared no fuss in with this change. Didn’t see anyone having kittens about this change, a far cry from what I had observed with some software engineering and/or tech operations teams teams. Clearly the mission of saving or mending lives is a greater leveler in the relative mundane changes with use of new tools and presentation of information. It was late this evening so I didn’t get the opportunity to ask the Nurses what they made of the changes. I will get to this during my next visit and may be even ask the patient coordinator if they have been on any training relating to Lean principles.

I also came across interesting sites/articles relating to Lean in Healthcare

• site: Lean Healthcare Exchange
• blog: Kaizen Corner – standardized work

The blog on standardized work is by a CEO of a large Boston hospital.When I first read this I wasn’t convinced that there is a call for standardized work. You see the work performed by Health care workers is one that touches people when they are most fragile and really some variability is desired by both the care giver and the patient alike. In software engineering there are standards that the coding and testing practices are measured to, but the standards adopted by an organization are used as a framework within which teams are expected to deliver their product. So no two people, though equally trained, will approach laying down the track of code the same way. Within this there is great deal of variability due mainly to style and level of experience.

Besides this standardized work as seen on a Toyota production line is not a comparison one wants to make when addressing Healthcare. For one machines have no cognition nor expectations. My biggest objection with a call for standardized work in health care is that this will replace the rational thinking that is needed, you know the act of doing as it is in the standards. I am sure there is fine balance between standardized work and what may be micro-management.

However, having said this and seeing at first hand the investment in information technology that has been made, I do see the opportunity of standardized process and work flow, as an example the nurses Kanban board. This no doubt can help with better coordination in services the patient receives, such that there is an order in which a particular set of services are best received. This last point is critical idea of standardized work that is addressed in the article. In fact, I realize the article does talk about benefits that can be achieved through standardized process by which work is gated and within which learning occurs. It also points out how visual cues/flags can help signal and thus avoid errors.

…… returning to my original thoughts – I still wonder if they routinely have retrospective meetings that promote Kaizen – continuous improvement.

Healthcare – Agile/Lean principles and Kanban/Scrum practices in ER

Yesterday I spent some 7 hours in a local Hospital attending a family member to the ER. That morning, I had quickly scanned through my copy of Lean-Agile Pocket Guide for Scrum Teams by Alan Shalloway & James R. Trott. This truly is a bible for Agile teams, note the operative word here is Teams. Anyways, this is my hindsight account of one persons Hospital ER experience, in particular how they have adopted Agile practices and Lean principles, proving to me that the current wave of Agile/Lean in Software development is actually behind the maturity curve of practices that have already been successfully adopted in what is otherwise Life or Death situation. I don’t say this lightly, given the hospital in question is also coping with the turmoil that building expansion brings to otherwise an operational environment.

When entering the ER, given that the family member was in a stable condition i.e not needing to be rushed to an OR theater, first we had to register the patient (register onto the backlog). I had come well prepared with as much detail regarding the patient, including details such as insurance details, age, height, weight, current prescription details, snapshot of test results collected in the past month and finally any changes seen in the past week leading up to the incident needing to rush him to ER. This was all recorded onto the electronic platform. There after we waited some 10-15 minutes to be seen by the Triage Nurse, I later learn from the attending nurse, the people filling in this role are really the overall ER team Product Owner/Champion and Scrum Master. Soon enough we were in ER exam room, as we made our way there I noticed few very large LCD displays along the two corridors that were the main artery through which Nurses, Doctors, Auxiliaries, Diagnosticians made there way when hustling between rooms (exam, medical dispensing store etc.)

During the next 6.5 hours from time to time I studied the LCD panels, and made out that these were really the Kanban/Scrum board – team work board. After the family member is seen to by couple of diagnosticians who performed a range of tests, such as temperature, BP, blood, urine, EKG, X-ray and CT Scan, each test being source of not just greater complexity for the lay person, but more important then this was how smoothly the flow was amongst all these people without ever conflicting in both time or space. As I later learned that all these on-goings was being updated on the Kanban board. Few hours into the ER exam room, when things had quietened down, I asked the attending Nurse:

[Q] How do they coordinate their work effort?
[Q] How should I read the board being displayed on the LCD display?
[Q] How is the board used?

I pointed out how fascinated I was at the smooth flow in work, remember this is an ER room, where the unexpected is the expected. She smiled and briefly explained that the Triage Nurses who take in the patients size the problem and assign resources based on the story. First the allocation is of the Nurse (Technical Champion/Business Analyst) and a Physician (Product Champion).
So I asked:

[Q] How do they ensure no one is gaming the system, and skipping out on the undesirable duties that may come there way?

She pointed out that when assignments are made, this is done based on complexity, number of patients being attended to and availability. The boards were a snapshot of state of the resources (rooms, health workers, diagnostics requested and completed). These boards represented the open and honest communication that allowed the smooth flow within the overall system of managing ER. She pointed out, for instance at sometime she may be attending only 1 or 2 patients, when compared to her colleagues who during that time may be attending to 4 of 5 patients. This really depends on how complex the needs of the patients are. There is a feedback loop on which the Nurses cycle back the size & complexity information to the overall product champion, the triage nurse who defines the assignments.

The interesting thing was the information on the Kanban board, I’ll call it that as this appeared to limit the Work-in-Process (WIP). This had a headline metrics of:
Waiting Room:2 Active Patients:19 Ready: 10 Dirty: 0 WTBS:0 TBADM:3 (the numbers are just part of a snapshot)
(WTBS – waiting to be seen, TBADM – to be admitted, Dirty – room is unoccupied but dirty from work on last patient)

The board by which the team managed its work had following elements (not all elements are listed here)

RN, MD, Gender, Age, Status, LOS, LAB …
(LOS – Length of Stay)

Here is a snapshot of the

ER Kanaban board

In addition to the Kanban board, the Nurse had informed me that when they need more details relating to the story, then they just logon to the system from any number of free standing terminals (on mobile platforms) and get to the centralized information. What was joy to watch, even in the circumstance of a family member in ER, was the sustainable and rhythmic flow of work (cadence). Contrast this to the work of Software Development environments that carry the baggage of being acclaimed with highly compensated information workers who often encounter a hard time with basics like having a open and honest communication channel, daily stand up meetings, decision making that optimizes the overall system, and critically Scrum or Kanban board to instrument smooth work flow by bringing visibility and transparency for the work of the team.

Outside the ER setting and on the ward I saw what I would call a Scrum board, this was a white board by Nurses station on the floor and it indicated assigned stories that a team of Nurses were working on. Some were co-owned and I can only assume that the physical need associated to taking care of the customers (patients) need being that much greater and called for collaboration. In addition to the Scrum board I noticed that the wards were equally dotted with free standing terminals which enabled the Nurses to get to the detailed information that was needed to support the work in progress against each story. I wonder if they routinely have retrospective meetings that promote Kaizen – continuous improvement.

Here let me share what I was thinking of while travelling between floors in the hospital. I put on my Product Champion hat on and figured the following products could greatly increase the efficiency with which each patient/story is managed and thus contribute to optimizing the whole – in this case the Healthcare system. So here are a set of stories (epics) I’d want to have my backlog and humbly say it would be great if:

• At check-in I am able to supply trend charts, in electronic format, for some of the routine snapshots in picture of health and well being. For instance common trend charts could be a time history of Temperature, Blood Pressure, Weight, Blood panel work, Xray etc. as measured at various visits during the course of prior 12 months. There may be trend charts for less frequently measured bio-information such as EKG, CT Scan, Ultrasound (Kidney, Heart etc.). All of this could better define the context and condition of the patient prior to the current event. The trend charts may lend themselves to detecting anomalies in condition and potentially allow for better preventative care.
• Diagnostic equipment (thermometers,blood pressure units, IV feeds) were smart sensors – lets say blue tooth and web services enabled. This follows the Lean principle of eliminating waste where by data is otherwise recorded today in analog form and maintained in a separate paper record system would now be digitally available and integrated within the overall patient record system. One can imagine health workers carrying a handheld device much like the FedEx/UPS delivery crew do, recording and transmitting information off the smart sensors corresponding to the patient in their charge. I have no doubt there are efficiencies of scale that will not only contribute to lowering healthcare cost through following the Lean principles of Optimize the whole (the patient, the resources), Deliver fast and in essence emphasis the two main categories, defined by as the authors of Lean-Agile Pocket Guide for Scrum Teams, as being central to the Lean principles and Agile practices – that of achieve fast flexible flow (A-F-F-F) and Discover what is needed (D-w-i-n).

As a foot note, with the Healthcare reform debate raging let me just add following statement when it comes to testing. In software development one part of the Quality Assurance strategy is to seek greater automation in testing. This is in line with the Lean principles of eliminating waste, deliver fast, optimize the whole and build quality into the software product. In healthcare much is made about over testing and often to the lay person there is a perception that much of the routine testing that one encounters is wasteful, especially if the same parameters are measured on frequent visits. Let me also add the disclaimer that providing trend charts, mentioned above, does not necessarily preclude the need to undertake some or all of the routine tests on each occasion. This data is just snapshots in time and when it comes to health systems I am reminded by the fine print from another health system of sorts, and that of DMV test report. This spells out that its just a snapshot and a pass does not provide mean an assurance against a failure in the near future, may be even on the same day.!