6 Toyota Production System Concepts to Improve ASC Efficiency
At first glance, healthcare and the automotive industry have very little in common. However, when looking at how both healthcare and the automotive industry conduct their daily operations, more similarities can be seen.
Steve Taninecz, a trainer, educator and coach with the Pittsburgh Regional Health Initiative, sees comparisons between the two industries in that both involve the "process of a day." "Both industries require sustaining processes and both look towards lean thinking," he says.
Joshua Manuel, industrial supervisor of IET, a full-service industrial and manufacturing engineering firm that serves healthcare providers, agrees. "We've seen a lot of former automotive manufactures now serving as healthcare leadership," he says. "There is value in hiring these professionals because they are used to cost-cutting industries."
Here is an overview of the Toyota Production System and six ways it can help ASCs improve their operations efficiency.
What is the TPS?
The Toyota Production System is a system that combines both the company's management philosophy and practices and combines rigid production activities with flexible operations to improve the flow of production. The main of objections are to design out overburden and inconsistencies and to eliminate waste.
According to a 1999 article in the Harvard Business Review by Steven Spear and H. Kent Bowen, the fundamentals of the system can be explained in four "rules":
- "All work shall be highly specified as to content, sequence, timing and outcome."
- "Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses."
- "The pathway for every product and service must be simple and direct."
- "Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization."
Although originally designed for the manufacturing industry, when broken down to these rules, the principles of the system can be effective for healthcare.
Laura Mahood, a project manager, educator and coach with PRHI, says that the comparisons between the industries may seem difficult to make but when one takes a look at how both industries operate, the similarities are there. "Obviously, in healthcare, the goal is to take care of patients not building cars," she says. "However, they both include complex systems and require looking at processes. Any work anyone does [at both a surgery center and a factory] is a series of processes designed for a specific outcome."
Six TPS applications for ASCs
1. Observation and visualization can help identify problems. In TPS, one of the major steps to waste reduction is to eventually develop a culture that can recognize and stop problems so that it can get quality right from the beginning. According to Barbara Jennion, director of PRHI's Perfecting Patient CareSM program, which trains healthcare providers on elements of TPS, observing processes within an ASC and then mapping them for inefficiency is crucial to the success of this program.
"After leaders observe the processes and flow at their centers, we put these observations on a value-stream map," Ms. Jennion says. "Comparing the processes to the map can help leaders understand how to identify breakdowns in the process and waste. Then, they can create programs with employees to see all forms of waste and highlight the work that needs to be done."
Mr. Manuel agrees with this process. "There's something to be said at looking at [what should happen versus what is happening] on a map," he says. "You can see the interaction between key resources and look at how to improve."
2. Communication is essential to effective processes. Rules two and three from the Spear and Bowen article emphasize the importance of a direct customer-supplier relationship and simple pathways for products. In manufacturing, this relates directly to a physical end-product — a car seat, a door, bolts, etc. In healthcare, these concepts can apply to caring for patients with one simple concept: effective communication.
"Waste is often the result of a communication breakdown," Ms. Jennion says. "In surgery centers, this is often due to reception or surgery staff not having what they need, such as prescriptions, test results or release forms, prior to the start of surgery. As a result, the flow of the process backs up due to processing or sending out for more information, and wait times increase as a result."
Process delays and other breakdowns in flow of work often occur when patients move from one area of the surgery center to another, according to Mr. Manuel. "We have seen inefficiencies in patient hand-offs and in technology," he says. "Staff members can be stuck in rework loops with paperwork, when it can be handled more efficiently with e-mail software or electronic health records."
Ms. Mahood notes that mapping these communications between areas of your surgery center can help identify these breakdowns. "In healthcare, people are departmentalized. Mapping can help leaders see how departments connect and help to break down barriers that may be put into place as a result of departmentalizing."
3. Standardization helps simplify processes. Individual departments or surgical teams in surgery centers often perform the same work by using different processes. This variation in processes, from scheduling to equipment used for similar procedures, can be the root cause of these breakdowns of communication.
According to Mr. Manuel, standardization is the best way to keep pathways simple and direct. "Most healthcare leaders understand what it is but not how important it is," he says. "Standardization is really the only way to get control of a process. That way if a problem occurs, you can trace the issue to the step in the process and can adjust immediately."
Ms. Mahood notes that this issue with standardization is most often seen in ASCs that have patient flow problems. "Most surgery centers operate by 'pushing' patients through the system: A patient presents to registration, completes the necessary paperwork and is then pushed through to the next area regardless of if the station is ready to handle them or not," she says. "We try to modify surgery centers to move from 'push' to 'pull.' Rather than having processes driven by the front-end, we move this to the back-end."
Standardized signals that are typically visual or non-verbal can help to facilitate this movement. Ms. Mahood suggests using a light or an audible cue to signal to the front-end when the back-end is ready for the next patient. This can cut down on wait times and prevent patients from being corralled into a single waiting area.
Mr. Taninecz suggests color coding and checklists as other means of standardizing processes. "Many centers use surgical checklists to help organize their staff members before surgery," he says. "These help to ensure that a flag will be raised if you go off the path you should be on."
Standardizing the set of tools surgeons use for similar procedures can also save an ASC time and money.
Ms. Jennion says, "These processes help keep the 'pull' going. We see a flux in production if every team does it differently. With standardized practices, everyone knows when something needs to happen, where they need to be and how they need to do it."
4. Engage staff members to help with implementation. In his experience helping healthcare companies implement TPS, Mr. Manuel says that it is easier to make changes when employees are involved with the process.
"We have employees and leaders help to develop the tools necessary to train their peers in the new process," Mr. Manuel says. "For instance, [in one center], we wanted to develop a new patient information packet to send to referring physicians. We sat down as a group and came up with what should be included."
Linda Horwitz Vicaro, an educator, trainer and coach with PRHI, says developing these problem-solving tools is fairly straightforward. "Toyota uses a very scientific process. You put together a report to provide a structured way of knowing what the problem is and then you drill down to the root cause of the problem. Then you develop a very specific implementation plan."
The next step in implementation can include a pilot program for one area of your surgery center. "During this step, you need to look for problems in the new system and adjust accordingly," Mr. Manuel says. Then, the plan can be rolled-out to the entire center.
Ms. Vicaro notes that it is important to measure the new plan against the old plan to see how areas, such as patient satisfaction, have been affected.
5. Commitment from leadership is essential to changing a culture. Spear and Bowen note that in TPS, in order to make changes to improve work, guidance from a teacher is necessary to ensure that improvements are made according to the scientific method and are applied to the lowest possible organizational level. For this reason, it is important for ASC leadership to commit to changing the culture so they can guide and teach the processes throughout the ASC.
Mr. Taninecz says, "Leadership needs to be on board and focus on their role and what they need to do."
Ms. Jennion agrees: "You need to stress the importance of the leadership role in making improvements. If they are committed, they will allow the culture to blossom."
6. Changing a culture presents some challenges. As with any new policy, surgery centers will face challenges when implementing these changes. Mr. Taninecz says, "People work very hard in center, but there are many wasteful practices. It will be necessary to help them understand that just because they've always done things this way, it doesn't necessarily make it the right way."
Mr. Manuel mentions some of the challenges working with physicians in a surgery center can face when trying to implement a change in culture. "You will get some negativity from low performers. It can be a struggle because a physician is not just an employee; they are also a customer, and if they are unhappy they will take their business elsewhere," he says.
Offering physicians incentives may be one way to help ease this skepticism. "Low performers make up a small percentage of the center," Mr. Manuel says. "We try to let them reap the benefits of performing." For example, at one facility, if surgeons showed up on time for surgery 85 percent of the time in one quarter, they were allowed to keep their current schedule or take over slots of a low performer.
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