SummaryUsing a methodology adapted from Toyota Production System principles, William Beaumont Hospitals implemented many small, rapid-cycle process improvement projects designed to improve overall patient flow and workflow, including increasing the amount of time nurses spend with patients. The projects represent a cultural shift in how the organization approaches quality improvement by involving management and frontline staff on teams and teaching them to carefully observe problems, identify countermeasures, quickly implement solutions on a small scale, and sustain successful improvements. Many areas, including a medical/surgical unit, patient transportation, pharmacy, and the emergency department, have undertaken projects that resulted in meaningful improvements in various process and outcomes measures. Examples include significant increases in nurse time spent with patients, shorter patient waiting times, faster radiology test turnaround, fewer missing and discarded medications, and greater staff engagement.Moderate: The evidence consists of pre- and post-implementation comparisons of a variety of project-specific metrics tracked by the implementing units and departments.
Developing OrganizationsWilliam Beaumont Hospitals
Date First Implemented2009
Problem AddressedMany hospitals routinely employ inefficient, unproductive processes that lead to small operational problems that take nurses away from patients, impede patient flow, and prompt "workarounds," thus causing delays in care and staff frustration.
- Little time for patient care: Nurses spend most of their time on nonpatient care activities. For example, a Kaiser Permanente study of 767 medical/surgical unit nurses found that patient care activities accounted for only 19.3 percent of nursing practice time.1
- Due primarily to work process inefficiencies: Relatively small inefficiencies and work obstacles in hospitals (e.g., the inability to quickly find supplies or equipment, poor communication/coordination between departments) can, in aggregate, have a major negative impact on the amount of time nurses can spend with patients. These problems often cause nurses to employ "workarounds" that lead to further inefficiencies and delays in patient care/flow.2 One study suggests that the typical unit-based nurse encounters one small operational problem every hour and that nurses manage 95 percent of these problems through workarounds.3
- Leading to staff frustration: Nurses at William Beaumont Hospitals expressed frustration with inefficient work processes, noting that the need to work around these problems took them away from engaging in value-added activities, such as caring for patients.
Description of the Innovative ActivityUsing a methodology adapted from Toyota Production System principles, William Beaumont Hospitals implemented many small, rapid-cycle process improvement projects designed to improve overall patient flow and workflow, including increasing the amount of time nurses spend with patients. Many areas, including a medical/surgical unit, patient transportation, the pharmacy, and the emergency department (ED), have undertaken projects to improve workflow efficiency. The projects represent a cultural shift in how the organization approaches quality improvement by focusing on identifying problems through direct observation rather than hearing about them in meetings; testing changes rapidly via quick experiments versus via extensive planning and discussion; and placing responsibility for improvement in the hands of small teams of management and frontline staff rather than management alone. Selected examples of these projects are described below:
- Medical/surgical unit project: A medical/surgical unit implemented hundreds of small adjustments to work processes, with the goal of making nurses more efficient by eliminating distractions and non–value-added work steps. Examples include the following:
- Easy-to-access pill cutters: Previously, nurses searched the unit for pill cutters several times a day. Now they can easily find the pill cutters, which have been anchored to the wall near the medication station.
- Supplies and computers in patient rooms: Commonly used supplies are now available in patient rooms, eliminating the need for nurses to search for supplies in centralized storage areas. In addition, all patient rooms now have computers so that nurses do not have to travel to the nursing station to review the patient's medical record or document care.
- On-unit wheelchairs: Hospital volunteers make sure that the unit always has a wheelchair available, thus allowing discharged patients to be promptly transported to the lobby. This approach eliminates the need for nurses to search for a wheelchair.
- Unit secretary rounding to handle basic requests: The unit secretary conducts hourly rounds to handle basic patient needs (e.g., providing a glass of water), reducing the need for nurses to interrupt their activities to handle such requests.
- Patient transportation project: The patient transportation department implemented improvements designed to address current inefficiencies, such as the inability to locate an available stretcher and patients not being ready when transporters arrived on the unit. These situations often led to nursing interruptions and care delays. Key improvements include the following:
- Stretcher storerooms: Transporters now obtain stretchers from designated "stretcher storerooms," with the transporters rotating responsibility for collecting and bringing stretchers to these rooms.
- Electronic notification of transporter arrival: The hospital's electronic transporter scheduling system now alerts the unit secretary via pager as to when the transporter will be arriving on the unit, with the page coming 10 to 15 minutes before anticipated arrival. The unit secretary then notifies the nurse, who ensures that the patient is ready for transport at that time. If the patient cannot be ready, the unit secretary contacts the transportation department to reschedule.
- Medication dispensing project: Historically, pharmacy and nursing systems were not well coordinated, resulting in nurses not having prompt access to intravenous (IV) medications when needed and to a meaningful number of missing IV medications. Calls for missing medications pulled nurses away from patient care and resulted in the pharmacy preparing a second dose of the same medication and wasting one of the two doses that had been prepared. The project put in place the following solutions to enhance efficiency:
- Medication dispensing closer to administration time: Previously, the pharmacy would batch-fill orders for IV medications three times daily (approximately every 8 hours, although some medications were filled up to 17 hours ahead of scheduled administration). Consequently, medications often had to be discarded when physicians' orders changed. Now, the pharmacy formulates IV medications in 10 batches each day, meaning that medications are created much closer to the scheduled administration time so that there are fewer discarded medicines. Eventually, hospital leaders hope to transition from this batching approach to "real-time" preparation.
- Changes to workflow during cleaning of sterile rooms: The pharmacy utilizes two clean rooms to prepare IV medications. Monthly, these rooms must be closed for a deep clean, during which one room is closed to undergo the deep clean and all medication preparation is consolidated in the other clean room. The process is then repeated during the month for the other clean room. The hospital experienced delays in the preparation and dispensing of IV medication when one clean room was closed for the deep cleaning. During a Kaizen event, workflow was changed to avoid delays in getting these necessary medications to patient care areas.
- ED project: Improvements in ED processes include the following:
- "Just-in-time" retrieval of patients requiring radiology tests: The radiology department often experienced delays because of ED patient batching. The ED nurse would complete all aspects of patient care on multiple patients, and then these patients would be taken to the radiology area for testing. This batching would overwhelm the radiology suite with patients, causing patients to wait in the radiology area for their test. Now, radiology technicians retrieve patients from the ED only when they are ready to perform the test.
- Distraction-free zone: A former storeroom has been designated a "distraction-free zone" where physicians can write orders without being interrupted.
- Expedited admissions from ED: Previously, the inpatient admission process for ED patients (e.g., collecting of insurance information, notifying the unit nurse, cleaning the room) would commence only after a laboratory workup had been completed. Now, the admission process begins as soon as the ED physician and nurse decide that admission is likely, even if the laboratory workup has not yet been completed.
Context of the InnovationWilliam Beaumont Hospitals, a three-hospital system in the Detroit metropolitan area, has 1,744 beds, employs more than 14,000 full-time equivalent staff, and handles more than 96,000 inpatient admissions each year. The system includes Beaumont Hospital Royal Oak, Beaumont Hospital Troy, and Beaumont Hospital Grosse Pointe. Dr. Samuel Flanders' experience with the Toyota Production System principles at his previous hospital position was quite positive, and he encouraged William Beaumont system leaders to embrace the rapid-cycle process improvement approach as a way to improve patient flow and workflow and ultimately change hospital culture. They decided to focus on increasing the amount of time nurses can spend providing hands-on care to patients, which they viewed as being critical to achieving significant improvements in quality.
ResultsMany of the rapid cycle projects have led to meaningful improvements in various process and outcomes measures. Examples include significant increases in the amount of time nurses can spend with patients, shorter waiting times for patients, faster radiology test turnaround, fewer missing and discarded medications, and greater staff engagement.
Moderate: The evidence consists of pre- and post-implementation comparisons of a variety of project-specific metrics tracked by the implementing units and departments.
- More time for nurses to spend with patients: Nurses on the medical–surgical unit that implemented the previously described improvements significantly increased the percentage of their time spent on direct patient care, from 34 percent before implementation to 54 percent afterward.
- Shorter wait times for patients: Several projects have reduced waiting times for patients, as outlined below:
- Fewer long waits for transports: Before the process improvements, 14 percent of patients had to wait 45 minutes or longer for a transporter (with wait time being defined as the time between the initial call for a transport and patient pickup). At present, less than 2 percent of patients wait this long.
- Quicker admissions for ED patients: Previously, ED patients in need of an inpatient admission typically had to wait 4 to 8 hours after the admission order before being placed in an inpatient bed. Since implementation of the previously described improvements, average waiting time has been reduced by 50 minutes.
- Faster radiology test turnaround, leading to higher satisfaction: Average turnaround time for ED patients in need of radiology testing decreased from 36 to 30 minutes. As a result, ED patient satisfaction with radiology services has increased by 3.5 percentage points.
- Fewer missing and discarded medications, leading to cost savings: Anecdotally, nurses report that they almost never face a situation in which they do not have a medication available for administration. As a result, the hospital has to discard fewer bags of IV medications, thus saving an estimated $400,000 each year. Part of this improvement is attributable to IV medication preparation being closer to the time of medication administration and reduced IV medication preparation time during days when two clean rooms are consolidated into one (resulting in a reduction of IV preparation time from 32 to 12 minutes).
- Greater staff engagement: On the medical–surgical unit, staff engagement scores from a Gallup survey increased from 3.71 before implementation to 3.98 afterward; this change was statistically significant and was the second largest improvement in scores seen among all the hospital system's nursing units.
Planning and Development ProcessA process improvement system developed by Toyota Motor Company incorporates different tools and techniques that can help reduce waste, lower costs, and enhance productivity while simultaneously increasing quality. Initially embraced by manufacturing companies, these methods have been implemented by a growing number of health care organizations. William Beaumont Hospitals undertook the following planning and development steps in adapting Toyota Production System principles to its own rapid-cycle improvement process:
- Executive buy-in: Implementation of the rapid-cycle improvement process began after the president of Beaumont Hospital Royal Oak approved the approach. The health system's chief quality and safety officer then described the process to the health system's entire senior leadership team, with the goal of spreading the process to the other two hospitals. These senior leaders attended some of the 2-day, rapid-cycle process improvement events held at Royal Oak (described below). These events are now being expanded to the other two hospitals.
- Training and facilitation: Several key organizational leaders received training on the Toyota Production System principles at a medical device manufacturing plant in Ohio. These leaders participated on the production assembly line and learned how to do rapid-cycle improvement. Hospital administrators contracted with two Toyota-trained consultants (who previously worked with the manufacturing plant) to train staff and serve as coaches/facilitators for improvement activities.
- Rapid-cycle improvement events: Process improvements are developed and implemented during 2-day, frontline observational "rapid-cycle improvement events." These events, which occur approximately four times each month, help to identify and address inefficiencies through relatively small, incremental improvements that can be designed and tested. Participants include administrators, managers, staff, and a trained facilitator who provides assistance as needed. The days are structured as follows:
- Day 1: Participants receive a 30-minute orientation describing the purpose and method of the rapid-cycle improvement event. This team then observes work flow, defines problematic elements, and brainstorms possible process changes. Next, the team implements changes and observes results. Changes must be safe, relatively quick to implement, low-cost, and easily reversed if they do not work.
- Day 2: The team continues to observe and try changes; it then decides which changes were successful and how to sustain them.
- Ongoing improvement: After participating in a few events, department/unit staff identify opportunities and implement them on their own, thus allowing process improvement to become an ongoing, continuous activity.
- Spreading improvements throughout system: Once improved processes have been adopted on one unit, they often spread organically as staff from other areas see the improvement and decide to adopt or adapt these ideas on their own units. In some cases, staff participate in 2-day events held outside of their unit, thus facilitating the spread of ideas.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: Program costs consist primarily of the fees paid to the two Toyota-trained consultants, which totaled approximately $250,000 between May 2009 and October 2010.
Funding SourcesWilliam Beaumont Hospitals
Getting Started with This Innovation
- Ensure that senior leaders become personally involved: Encourage senior leaders to participate in process improvement activities so that staff understand their importance to the organization. Leadership support is also critical to an overall organizational culture change.
- Do not "oversell": Discussing process improvement excessively—or even giving a formal name to the initiative—may make staff view the effort as just another fad. The better approach is to remain "low key" by simply holding the improvement events, with the hope that staff will be swayed by their effectiveness and promote the concept to colleagues.
- Use trained coaches: Trained coaches can ensure that staff understand how to actively observe a work process and develop ideas for improvement. Trained coaches can also keep teams on track by redirecting activities and conversations as needed.
- Focus on simple measurement: In some cases, formal, indepth measurement can be complicated and time-consuming, and hence delay adoption of effective ideas. Often, simple metrics and anecdotal feedback from staff can be enough to determine if a small process improvement is working.
Sustaining This Innovation
- Involve all staff: Ensure that staff at different levels of the organization participate in process improvement events. This inclusive approach builds enthusiasm for the process and makes staff more inclined to pursue improvements on their own.
- Encourage culture of improvement: The 2-day events should not be regarded as the only time to focus on improvement. Rather, staff should be encouraged to proactively look for opportunities for improvement and to develop straightforward solutions outside of these events. For example, on the medical–surgical unit at Beaumont Hospital Royal Oak, staff keep an ongoing list of problems or "workarounds" they encounter, and they routinely brainstorm solutions to address these issues.
- Program developers emphasize that an institution-wide cultural change is crucial for program success. They emphasize that several features differentiate the William Beaumont Hospitals' approach from more traditional methods of quality improvement. First, very few meetings are involved. Second, improvement ideas are based almost entirely on direct observation of the work being performed versus discussions with staff and management. Finally, the speed of improvement is much faster than is typically seen. By focusing on what can be done on a small scale "in the moment" and coaching participants into thinking creatively, participants suggest solutions that otherwise would be missed. Participants are encouraged to try anything as long as it is safe, relatively quick, inexpensive and can be easily undone if not effective; in this environment, experimentation (and failure) is perfectly acceptable as long as the participants learn something.
- Furthermore, program developers emphasize that this effort is primarily about empowering and then teaching people to make changes in their work environment. Culture drives behavior and behavior drives results. This approach requires a different leadership style than traditional "command and control" environments. Leaders must become coaches and help clear away organizational barriers to allow the workforce to succeed. Coaches at William Beaumont do not usually suggest solutions themselves, but help participants to find them. This results in much greater ownership and buy-in because people naturally want their own ideas to succeed. Patience is required and diffusing this approach through an organization may take 3 to 5 years or more.
Contact the InnovatorSamuel Flanders, MD
Executive Vice President, Quality, Safety and Clinical Effectiveness
Beaumont Health System- Corporate Administration
3711 W. 13 Mile Road
Royal Oak, MI 48073
Administrative Director, Professional Services
Director, Pharmaceutical Services
William Beaumont Hospitals - Hospital Administration
3601 W. 13 Mile Road
Royal Oak, MI 48073
Innovator DisclosuresDr. Flanders and Ms. Pawlicki have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesGreene J. Beaumont waste-cutting gives nurses more time with patients. Crain's Detroit Business. January 10, 2010. Available at: http://www.crainsdetroit.com/article/20100110/HEALTH/301109993/1068#
Hendrich A, Chow M, Skierczynski BA, et al. A 36-Hospital Time and Motion Study: How do Medical-Surgical Nurses Spend their Time? Perm J. 2008 Summer;12(3):25-34. [PubMed]
Hassmiller SB, Cozine M. Addressing the nurse shortage to improve the quality of patient care. Health Aff (Millwood). 2006;25(1):268-74. [PubMed]
3 Tucker A, Edmondson A. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. California Management Review 2003;45(2):1-18.
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Original publication: March 30, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 05, 2012.
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