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WEEKEND EXTRA

BY AMY O’BRIANVANCOUVER SUN

O ver the course of five days inJanuary, a ser ies of smal lchanges — which promise to

have big implications for patient wait-ing times and patient safety — werequietly made in a few of Vancouver’sbiggest health care facilities.The changes were not trumpeted bypoliticians or braggedabout inpress re-leases. They were not the results ofmultimillion-dollar cash infusions or anewwave ofmedical graduates.Instead of throwing money at theirproblems, executives at the ProvincialHealth ServicesAuthority are throwingpeople at them.And they’redoing it in awaymodelled on the success of Japan-ese carmanufacturing giant Toyota.No, they’re not approaching patientslike they’re cars on an assembly line.But they areusing a Japanese-speakingsensei or teacher —who has ties to theToyota family— tohelp themeliminateinefficiencies and streamline their op-erations.“Nurses for years have told us thatthere is a lot of waste in the system,”said Lynda Cranston, president andCEO of the health authority. “So we’vebeen asking, ‘Are we actually being asefficient and effective as we can? Andare we providing you with an environ-ment that is efficient and effective, soyou can do your job?’ ”

Carmaker-inspired modelBureaucracies are, by nature, slowand sluggish beasts. While there isplenty of fast-paced action on the frontlines of hospitals and other health careagencies, the upper echelons of themedical systemareundeniably bureau-cratic. Suggest a change in the systemand it could take months or more tomake it happen.With the Toyota-inspired model,though, it took less than fivedays to im-plement seemingly small changes thatwill mean shorter waiting times for po-tentially life-saving procedures, morepleasant—and efficient—hospital vis-its for patients, and safer procedures.“It’s not about some bigger agenda. Ithas nothing to do with anything otherthan what it should be about — the pa-tient,” said Piper Shalley, a nurse whoworks in the pediatric intensive careunit.

At B.C. Women’s Hospital, a Toyota-based five-dayworkshopwas able to re-duceby90per cent the time fromwhena newmother is ready to be dischargedfrom the hospital to when she exits thebuilding and heads home. Before theprogram, thedischargeprocess took anaverageof 10hours.Now, it takes aboutone hour.Court-ordered psychiatric patientsused to have to wait 10 days to be ad-mitted to abed. Since theworkshop, it’sdown to an average of 3 1⁄2 days.At the BC Cancer Agency, staff wereable to reduce by 83 per cent the timefrom when a doctor made a referral towhen the patient got in to see a special-ist. Before the workshop, the averagewait was 42 days. Now, it’s seven.The changes cost the system next tonothing.

Changing small processesSo far, the Provincial Health ServicesAuthor i ty — which inc ludes BCWomen’s and Children’s hospitals, theBC Cancer Agency and the BC Centrefor Disease Control — has completed45 Toyota-inspired projects.All levels of staff have been included,from front-desk clerks to doctors tovice-presidents to the CEO. Groups ofeight or 10 people are thrown into aroom together, presented with the de-tails of the problem, instructed on howtomap it out, and then theybrainstormsolutions, implementing one of thembyweek’s end.“It’s not a matter of changing theworld. We’re just changing smallprocesses,” saidDr.KevinElwood, a tu-berculosis specialist at the BC Centrefor Disease Control. “It’s notmagic.”During the two workshops that havebeen done at Elwood’s clinic, the focuswas on “improving workflow process-es,” he said. Basically, that meant cut-ting out unnecessary physical and pro-cedural steps, cleaningup the filing sys-tems, and altering the appointmentsystem.The results have been shorterwaitingtimes for people needing to get a skintest for tuberculosis and for test results.“Now, you walk through and it lookslike nuns have come through andcleaned up the place for us,” he said.But there were no nuns — and nomagic— involved. Just a variety of staffplucked from different levels of thechain, and an outsider who could askall the naive, basic questions that those

entrenched in the system likely would-n’t see.Jan Christilaw, acting president ofB.C. Women’s Hospital, said the effi-ciency-finding missions — known asimPROVE within the health authority— have been effective, particularly foranorganization that hasbeenprimarilyoccupied with delivering babies andcaring for women.“Oneof the thingswe started tonoticein health care is that you get set in yourways. You get set in your ways of doingthings,” Christilaw said.“And it’s sometimes difficult for oneindividual, who works in any part ofhealth care, to stepback and say, ‘Thereare four steps in this process thatwe re-ally don’t need to be doing.’ ”Several other B.C. health authorities,includingVancouverCoastal andProv-idence, have also been using Toyota-based methods to tighten up workflowand eliminate waste. The philosophy iscommonly referred to as “leanmanage-ment,” and was first applied in earnestto the health care system at the begin-ning of the decade.Virginia Mason Medical Center inSeattle is considered one of the leadersin applying the lean philosophy tohealth care. The hospital began imple-menting lean strategies in 2002 andwithin three years, it had saved morethan$8millionUS in capital expenses.By increasing efficiencies, the hospi-tal was able to scrap plans for severalexpensive expansions, including newsurgery suites, a newhyperbaric cham-ber and new endoscopy suites.It was able to reduce the number offull-time equivalent staff positions by36 per cent, through attrition and reas-signing some staff to other positions.Therewere no layoffs.The Seattle hospital saved 53per centon inventory, reduced set-up time forsurgeries and bed moves by 82 percent, and reduced the distance thatstaff travelled during their shifts by 44per cent.The reasons for implementing “lean”strategies in B.C. hospitals are com-pelling. Our aging population, com-binedwith doctor and nurse shortages,means that more has to be done withless.“We believe there’s higher clinical ef-ficacy and outcomes by virtue of thefact that we’re more efficient. We’reable to do thingsmore efficiently,” saidLarry Gold, president of BC Children’sHospital and the Sunny Hill Health

Centre.“And from a taxpayer standpoint,we’re using our resources in as an effi-cient and effective way as we possiblycan.”

Improving safety, careBut lean strategies are also aimed atimproving patient safety and care. A2004 study published in the CanadianMedical Association Journal foundthat an average of 7.5 out of every 100hospital admissions results in an ad-verse event — such as an infection —but close to 70,000 of those each yearare potentially preventable. One inevery six incidents of adverse events re-sults in the patient’s death.A key objective of the leanphilosophyis to reduce such occurrences.It can be hard to understand the rea-sons for the overlaps, redundanciesand inefficiencies in thehealth care sys-tem. But not when you consider thatthe system has grown from a point ofnecessity, rather than profit. Addition-ally, it has had more layers added withnewmedical advancements, new fund-ing andmore patients. It is natural thattherewould be areas for improvement.Dr. Paul Bach, an anesthesiologist atSt. Paul’s Hospital’s heart centre, hadsomething of an epiphany in his think-ing about the medical system uponwalking into thewaiting roomone day.“There was one day where a numberof things conspired against me and Icame out to see a waiting room full ofpeople and I had to organize them tocomeback later in theday.And itwas atthat point I realized that the systemthat we had just wasn’t efficient,” hesaid.“In fact, as I thought more about itwhat I realized was our medical sys-tems were never designed. They grew.And they’ve sort of become cobbled to-gether in bits and pieces.”Bach was involved in an imPROVEproject that aimed to reduce the wait-ing time for patients to be assessed be-fore heart surgery. Before the project,patients were waiting an average of 71minutes to see the proper doctor. Afterthe project, that timewas reduced to 15minutes.“We increased the number of cardiacpatients we see by about 25 per cent,from 600 to more than 800, in oneyear, without increasing our staffinglevel or appointments— all becausewejust gotmore efficient,” he said.

“There have been lots of benefits, notjust patient wait times. It’s translatedinto seeing more patients, seeing themmore efficiently and making their sur-gical journey a much safer one in thelong run.”(St. Paul’s Hospital is not part of theProvincial Health Services Authority,but the heart centre was involved in animPROVE project because the healthauthority administers and funds allcardiac services for the province, re-gardless of where they’re delivered.)Executives within the health authori-ty talk eagerly about how imPROVE ispart of a larger “culture shift”within theorganization.

Some skepticismThe hope is that by placing the reinsof change in the hands of front-lineworkers, they will feel empowered. Byhelping staff feelmore empowered, thehope is that they will take increasedownership of their jobs.“There’s a much higher level of satis-faction with staff,” Gold said. “Effec-tively,we’re getting the right care to theright child with the right set of re-sources, at the right time.”Naturally, therewas some skepticismandhesitancy about imPROVEwhen itwas first rolled out in late 2007.But for those front-line workers whohave been immersed in one of theworkshops, it’s clear that these are nottop-down initiatives.“I would just say that I was very im-pressed,” said Shalley, the pediatricICU nurse. “It was focussed on the pa-tient and focussed on the people whoare required to care for the patient.”There is no end-date for the im-PROVEprocess. The idea is to continu-ally re-evaluate and redesign processesin all areas of the health authority, withimproved efficiency and safety as thekey objectives.“Eventually, what we would hope isthat five years fromnow,we’ll be able tosay, ‘We made fewer medical errorsand it’s because of this process’,” Chris-tilaw said.

aobrian@vancouversun.com

Shorter waiting times and improved safety are goals of plan patterned after Toyota system

Patients to need less patienceBILL KEAY/VANCOUVER SUN

Zoe Hodgson (right) gets check-in information at Women’s Hospital reception area. Changes in waiting times and safety have been implemented in a few of the biggest health care facilities in Vancouver.

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