Herb Robbins Shows How to Identify and Eliminate the Eight Inefficiencies in Healthcare
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With the myriad of processes that can take place within a healthcare environment, it’s no wonder that healthcare professionals find it a daunting task to drill down to the root cause of organizational process inefficiencies. Herb Robbins, President and CEO of Robbins International, a consulting firm that provides Lean Business and Six Sigma services to corporations and manufacturing organizations, has come up with a way to make this chore easier for the healthcare community. In this Six Sigma IQ interview, Robbins discusses the acronym he has developed, HOSPITAL, which identifies the eight inefficiencies that exist in all medical facilities and organizations, and shows how to leverage this tool, as well as Lean, for healthcare process improvement. (This interview has been taken from a transcript of a podcast that has formerly run on Six Sigma IQ. The interview has been edited for length.)
Please tell us a bit about your background and your company.
I attended a Marine Engineering School and sailed in the US Merchant Marines as a Third Assistant Engineer. I'm also a retired Naval Officer. I worked for 25 years in the electronics industry, primarily for Tyco International manufacturing Printed Circuit Boards for the Military, Aerospace and Commercial Industries. Starting as a process engineer, assigned to improve processes, I worked my way into managerial roles in Engineering, Quality, and Operations. Although I've used the tools of Lean and statistics my entire career, I began my formal Six Sigma training as a Green Belt with Honeywell in 2000. I earned my Black Belt with Tyco the next year and my Master Black Belt with SBTI the year after that. As Director of Six Sigma, with Tyco, I coordinated Green Belt and Black Belt trainings across the US, Spain and China as well as coached Belts with project work. I also worked with folks in other Tyco business units including Healthcare, Fire and Plastics.
In September of 2007, I started Robbins International with my partner Annette Stout and began consulting and training in manufacturing, healthcare and service environments. Our Web site, www.Lean2020.com has additional information of our offerings as well as free online White Belt training.
Let me describe my transition from manufacturing to healthcare. While with Tyco solving manufacturing issues, I was often confronted with office systems that were causing our company to do things inefficiently. These systems were not necessarily computer systems, but rather the methods used to complete tasks. What I found was that there were as many issues in the office to solve as there were on the manufacturing floor. It's at this time that I discovered that the same tools could be applied to the transactional world. I've later discovered that these can also be applied in education, healthcare and even in our own homes.
Healthcare organizations, much like military suppliers, are being forced to be more efficient. Gone are the $80 Tylenols and $500 hammers. With insurance companies capping these expenses, hospitals need to find ways to be more efficient.
The concepts of Lean are relatively new in these environments, and improvement opportunities exist at every turn. One could say a target rich environment. One other note: when we are in manufacturing facilities the term "waste" is commonly used for the inefficiency issues. The term "waste" in the healthcare world has a completely different meaning. In healthcare, we speak about eight inefficiencies and leave the waste to the medical folks to dispose of.
This would be a good time to introduce the HOSPITAL acronym and begin speaking about specific examples.
In order to improve any environment, folks need to be able to fix problems. These problems are not very apparent and without identifying issues, problems are not able to be worked on or solved. We provide folks with the ability to see the eight different inefficiencies that exist in all healthcare environments.
H is for Halting. Consider the huge amount of time that we spend stopped. We wait for test results, patients sit in the waiting room. Heck, we even call it a waiting room. Let’s not kid anyone—our patients go there and wait! From a time standpoint, this is probably the largest contributor to waste and inefficiency in the workplace.
Next is O for Overproducing. How many times do we write a patient’s name? On reports, logs, forms, and in computers. Why can’t we simply enter this one time? It’s not just the name that we write multiple times, there’s plenty of other information that needs to go on different reports, documents, and systems. There’s wasted time and the possibility to make a mistakes as we write or transpose information.
Next is S, which is for Slips. Think of the mistakes, errors and near mistakes that are made each and every day. These slips are costly. Certainly we’d want to avoid making them if possible. We waste time correcting them and fixing the fallout from what may have been effected. Issuing the wrong medication or incorrect dosage are examples of slips. There are error proofing devices and other tools which can help to reduce slips in healthcare.
Next is P for Processing, which is another big inefficiency. There are a number of processes that we perform that do not add value for our patients. We call these non-value added processes. There are three important items that would make a process value-added. The process needs to satisfy all three [or] else it is considered non-value added. First, does the step change or provide a service to the patient? Giving meds or physical therapy are examples of value-added processes. Second, is it done right the first time? Redoing blood tests or x-rays are examples of non-value added processes. Third, is the patient willing to pay for it? The patient needs to value the process, [or] else it is non- value added. If we provide them with something that they do not need, then that process is non-value added.
I is for Inventory. There is a huge amount of money tied up with inventory. Could that money be better used more efficiently elsewhere? Think about the extra storage space and time spent sorting through excess inventory to find what we need … all inefficiencies brought about by lack of inventory control.
T is for Transportation. We transport patients all over our medical facilities. Through elevators and hallways…wow…think about all this wasted time. We might even consider the flow of a document circulating for approvals. Think about the travel in steps that this takes, from one person to another. Transportation can be reduced by putting people and departments, who work closely with each other, next to one another.
A is for Action. This is similar to Transportation, but not the same thing. Think of Action as your motion, not the patient or thing in the process. You walk to the file cabinet and have to open three drawers before you find what you need. Ever look for a patient’s chart? That action or motion is wasted steps and time. If only we had these items more readily available [by being] properly marked in a common spot. 5S is a work place organization and cleanliness tool that will help us reduce and eliminate actions.
Finally our last inefficiency is L for Lack of Employee Engagement. How often are thoughts and ideas from employees ignored? I once heard a manager [say] to an employee, "I don’t care about your input. I care about your output!" Wow…that sent a message! Not the way I [would] want to motivate someone to work with me. Growth environments understand the critical value in their employees and helping them develop further by exposing them to new training and concepts is important. Employees perform processes daily and know how things are truly done. To change a process or system without their input is counter-productive. Employees need to be part of the discussions so that their ideas and concerns can be addressed and incorporated as deemed appropriate. I wonder if any listeners’ environments waste this precious resource.
[inlinead]How can Lean help hospitals drill down on these wastes or inefficiencies? Please provide a few examples to show the process.
There are a few critical steps required. First, one must be able to see the inefficiencies that exist. This may appear obvious, although I will tell you that I see shocked looks on peoples’ faces when I review our acronym, each and every time, it’s like a light goes on.
Every environment is a bit different and some are further along the improvement path. We recommend an owner, which is often a small team, who can direct the efforts. Lots of small changes can make a difference, although we’ve found that the greatest gains and enhancements are made when the entire facility is working together towards a common goal.
In this environment, projects can be identified and prioritized, best practices can be shared and spread through standardization, and better/stronger solutions can be implemented through the use of diverse, cross-functional teams.
Next, these teams can provide solutions that will potentially help a greater population than if they were working independently within their own departments’ silos.
What unique challenges may hospitals run into with trying to drill down to the root cause of inefficiencies? What Lean strategies do you suggest they follow to work through these particular challenges?
The biggest challenge is from the top. These enhancements, whether Lean or [some] other [methodology], are often seen as the next "flavor of the month." Administrators need to get the message out to all employees that in order to survive, we need Lean now and in the future. Lean has been around for hundreds of years and is needed now more than ever. We can all picture a car pulling up to a gas station in the 1950s, five people would emerge to check oil, tire pressure, clean windshields, fill the gas, etc. Today we swipe our own card and pump our own gas. The service industry has forever changed.
Additionally our staff needs to see the big picture. We’ve all heard the one—can’t see the forest for the trees. People easily become overly concerned with detail; not understanding the whole situation.
There are some basic tools—one is teaming—as briefly described above. Gather a diverse, cross-functional team that is more apt to see the big picture, even if the big picture is created as these individual team members explain each of their smaller pictures.
Next is process mapping—a visual way to display and work on problems. We often find ourselves fixing one problem and simply creating another; process mapping is another method used to see the big picture.
Once these inefficiencies are identified, what next steps should a hospital take in eliminating these wastes through the use of Lean? Which tools prove to be the most useful?
Through this entire process the champion or team directing these enhancements will need to provide additional training to staff. As they become more aware of the possible solutions, implementation can be done in phases or pilot testing can be performed to limit exposure to poor solutions. Most Lean solutions are relatively straightforward, although the follow-up on implementation is generally what lags.
How can hospitals ensure that they sustain these gains in efficiency?
The most important [part of] this entire process is sustaining the gains implemented. Training, documentation of new systems, and buy in are the most important elements. Lastly, the new system needs to make sense and if an easier way is discovered and being used or adopted by some, then this new activity needs to be used to enhance the existing process, or those folks need to understand the reasons why the existing process must be followed, whether for legal, regulatory or safety requirements.
Interview by Genna Weiss
Please tell us a bit about your background and your company.
I attended a Marine Engineering School and sailed in the US Merchant Marines as a Third Assistant Engineer. I'm also a retired Naval Officer. I worked for 25 years in the electronics industry, primarily for Tyco International manufacturing Printed Circuit Boards for the Military, Aerospace and Commercial Industries. Starting as a process engineer, assigned to improve processes, I worked my way into managerial roles in Engineering, Quality, and Operations. Although I've used the tools of Lean and statistics my entire career, I began my formal Six Sigma training as a Green Belt with Honeywell in 2000. I earned my Black Belt with Tyco the next year and my Master Black Belt with SBTI the year after that. As Director of Six Sigma, with Tyco, I coordinated Green Belt and Black Belt trainings across the US, Spain and China as well as coached Belts with project work. I also worked with folks in other Tyco business units including Healthcare, Fire and Plastics.
In September of 2007, I started Robbins International with my partner Annette Stout and began consulting and training in manufacturing, healthcare and service environments. Our Web site, www.Lean2020.com has additional information of our offerings as well as free online White Belt training.
Let me describe my transition from manufacturing to healthcare. While with Tyco solving manufacturing issues, I was often confronted with office systems that were causing our company to do things inefficiently. These systems were not necessarily computer systems, but rather the methods used to complete tasks. What I found was that there were as many issues in the office to solve as there were on the manufacturing floor. It's at this time that I discovered that the same tools could be applied to the transactional world. I've later discovered that these can also be applied in education, healthcare and even in our own homes.
Healthcare organizations, much like military suppliers, are being forced to be more efficient. Gone are the $80 Tylenols and $500 hammers. With insurance companies capping these expenses, hospitals need to find ways to be more efficient.
The concepts of Lean are relatively new in these environments, and improvement opportunities exist at every turn. One could say a target rich environment. One other note: when we are in manufacturing facilities the term "waste" is commonly used for the inefficiency issues. The term "waste" in the healthcare world has a completely different meaning. In healthcare, we speak about eight inefficiencies and leave the waste to the medical folks to dispose of.
This would be a good time to introduce the HOSPITAL acronym and begin speaking about specific examples.
In order to improve any environment, folks need to be able to fix problems. These problems are not very apparent and without identifying issues, problems are not able to be worked on or solved. We provide folks with the ability to see the eight different inefficiencies that exist in all healthcare environments.
H is for Halting. Consider the huge amount of time that we spend stopped. We wait for test results, patients sit in the waiting room. Heck, we even call it a waiting room. Let’s not kid anyone—our patients go there and wait! From a time standpoint, this is probably the largest contributor to waste and inefficiency in the workplace.
Next is O for Overproducing. How many times do we write a patient’s name? On reports, logs, forms, and in computers. Why can’t we simply enter this one time? It’s not just the name that we write multiple times, there’s plenty of other information that needs to go on different reports, documents, and systems. There’s wasted time and the possibility to make a mistakes as we write or transpose information.
Next is S, which is for Slips. Think of the mistakes, errors and near mistakes that are made each and every day. These slips are costly. Certainly we’d want to avoid making them if possible. We waste time correcting them and fixing the fallout from what may have been effected. Issuing the wrong medication or incorrect dosage are examples of slips. There are error proofing devices and other tools which can help to reduce slips in healthcare.
Next is P for Processing, which is another big inefficiency. There are a number of processes that we perform that do not add value for our patients. We call these non-value added processes. There are three important items that would make a process value-added. The process needs to satisfy all three [or] else it is considered non-value added. First, does the step change or provide a service to the patient? Giving meds or physical therapy are examples of value-added processes. Second, is it done right the first time? Redoing blood tests or x-rays are examples of non-value added processes. Third, is the patient willing to pay for it? The patient needs to value the process, [or] else it is non- value added. If we provide them with something that they do not need, then that process is non-value added.
I is for Inventory. There is a huge amount of money tied up with inventory. Could that money be better used more efficiently elsewhere? Think about the extra storage space and time spent sorting through excess inventory to find what we need … all inefficiencies brought about by lack of inventory control.
T is for Transportation. We transport patients all over our medical facilities. Through elevators and hallways…wow…think about all this wasted time. We might even consider the flow of a document circulating for approvals. Think about the travel in steps that this takes, from one person to another. Transportation can be reduced by putting people and departments, who work closely with each other, next to one another.
A is for Action. This is similar to Transportation, but not the same thing. Think of Action as your motion, not the patient or thing in the process. You walk to the file cabinet and have to open three drawers before you find what you need. Ever look for a patient’s chart? That action or motion is wasted steps and time. If only we had these items more readily available [by being] properly marked in a common spot. 5S is a work place organization and cleanliness tool that will help us reduce and eliminate actions.
Finally our last inefficiency is L for Lack of Employee Engagement. How often are thoughts and ideas from employees ignored? I once heard a manager [say] to an employee, "I don’t care about your input. I care about your output!" Wow…that sent a message! Not the way I [would] want to motivate someone to work with me. Growth environments understand the critical value in their employees and helping them develop further by exposing them to new training and concepts is important. Employees perform processes daily and know how things are truly done. To change a process or system without their input is counter-productive. Employees need to be part of the discussions so that their ideas and concerns can be addressed and incorporated as deemed appropriate. I wonder if any listeners’ environments waste this precious resource.
[inlinead]
There are a few critical steps required. First, one must be able to see the inefficiencies that exist. This may appear obvious, although I will tell you that I see shocked looks on peoples’ faces when I review our acronym, each and every time, it’s like a light goes on.
Every environment is a bit different and some are further along the improvement path. We recommend an owner, which is often a small team, who can direct the efforts. Lots of small changes can make a difference, although we’ve found that the greatest gains and enhancements are made when the entire facility is working together towards a common goal.
In this environment, projects can be identified and prioritized, best practices can be shared and spread through standardization, and better/stronger solutions can be implemented through the use of diverse, cross-functional teams.
Next, these teams can provide solutions that will potentially help a greater population than if they were working independently within their own departments’ silos.
What unique challenges may hospitals run into with trying to drill down to the root cause of inefficiencies? What Lean strategies do you suggest they follow to work through these particular challenges?
The biggest challenge is from the top. These enhancements, whether Lean or [some] other [methodology], are often seen as the next "flavor of the month." Administrators need to get the message out to all employees that in order to survive, we need Lean now and in the future. Lean has been around for hundreds of years and is needed now more than ever. We can all picture a car pulling up to a gas station in the 1950s, five people would emerge to check oil, tire pressure, clean windshields, fill the gas, etc. Today we swipe our own card and pump our own gas. The service industry has forever changed.
Additionally our staff needs to see the big picture. We’ve all heard the one—can’t see the forest for the trees. People easily become overly concerned with detail; not understanding the whole situation.
There are some basic tools—one is teaming—as briefly described above. Gather a diverse, cross-functional team that is more apt to see the big picture, even if the big picture is created as these individual team members explain each of their smaller pictures.
Next is process mapping—a visual way to display and work on problems. We often find ourselves fixing one problem and simply creating another; process mapping is another method used to see the big picture.
Once these inefficiencies are identified, what next steps should a hospital take in eliminating these wastes through the use of Lean? Which tools prove to be the most useful?
Through this entire process the champion or team directing these enhancements will need to provide additional training to staff. As they become more aware of the possible solutions, implementation can be done in phases or pilot testing can be performed to limit exposure to poor solutions. Most Lean solutions are relatively straightforward, although the follow-up on implementation is generally what lags.
How can hospitals ensure that they sustain these gains in efficiency?
The most important [part of] this entire process is sustaining the gains implemented. Training, documentation of new systems, and buy in are the most important elements. Lastly, the new system needs to make sense and if an easier way is discovered and being used or adopted by some, then this new activity needs to be used to enhance the existing process, or those folks need to understand the reasons why the existing process must be followed, whether for legal, regulatory or safety requirements.
Interview by Genna Weiss
