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    Adrienne Lloyd
    Adrienne Lloyd, MHA, FACHE

    Process improvement thinking is key to optimizing clinical flow, increasing team engagement and creating long-term practice success. Both Lean and Six Sigma methodologies can be utilized to identify opportunities and provide a structure for implementing change.

    Lean focuses on reducing waste to add value to the customer. Taiichi Ohno, who developed the Toyota Production System, originally identified seven types of waste: waiting, excess motion, excess transportation, defects or errors, overproducing, unnecessary processing and too much material or information. I believe there is an eighth — excess or wasted effort/time for staff and, in healthcare, providers. Six Sigma focuses, more specifically, on reducing process variation and standardizing outcomes. 5S methodology, a component of Six Sigma and originally developed by Hiroyuki Hirano, is an approach for organizing, cleaning, developing and sustaining a productive work environment. 5S benefits the organization by eliminating physical waste and search time, improving team member flow, serving as a foundation for visual management, opening floor/counter space for other purposes or cleanliness, and reducing training time and employee and provider stress.

    5S has tremendous value in practice optimization by minimizing excess motion, transportation, effort duplication, rework, and supply and other physical resources.

    One of the hardest parts of any successful process improvement initiative is convincing providers and staff that changes will, in fact, occur and stick. When beginning a process improvement initiative, I’ve found a visual transformation can kick-start team engagement, producing excitement for what comes next, while decreasing non-value-added effort that wastes time, money and energy. 5S helps you do just that.

    Start with a waste walk

    One method to engage your team is to lead them in a waste walk. As the leader, bring together a cross-functional group of team members, share with them the eight types of waste, and ask them to walk around the location and document each waste item on a separate post-it note. (Include both the waste type and location if doing multiple areas, such as excess supplies stuffed into cabinets in procedure room A). Then, regroup with team members and label large flip charts or boards in the room with the different categories of waste. Ask team members to place their post-it notes in the right category and then brainstorm with the team about root causes of the wastes and strategies to consider to prevent or eliminate them. Organize these ideas into an action plan tool (see Figure 1) so that you can prioritize and address.

    Preparing for the 5S event

    • Dedicate a focused block of time outside of busy hours: Most likely, the space you choose for your first 5S will be one that you use on a regular basis, meaning that it shouldn’t be “in-process” for too long or it could negatively impact your clinical flow. Therefore, it’s helpful to complete the initial phases of 5S in a focused block of time, usually one evening after patients have left or a weekend morning if necessary.
    • Gather materials and prepare the team: To ensure success, make sure the recommended supplies (see supply list) are available ahead of time and verify team members who will be involved understand the importance of 5S and the overarching goals for the event/space.
      • For your 5S event, it is helpful to have:
        • Trash bags or containers for discarded items
        • Recycling containers if high paper area
        • Plastic bins in different colors and sizes (sizes should vary based on items that need to be stored)
        • Label maker with plenty of tape!
        • Colored cards for Kanban cards and other visual queues
    • Make it fun! The team will enjoy seeing you and providers engaged in the decluttering process. Laugh at the inevitable over-ordering, secret supply stashing or hoarding that has occurred over time. When conducting a 5S in an ASC, we found $1,500 ablation catheters that had been stashed in procedure room cabinets rather than the main supply room. This caused our PAR system and manual counts to be off, making it seem as though we had more supplies than we did. We discovered that providers were responsible because they did not believe our old process was fail-safe enough to ensure they always had what they needed. Unfortunately, they forgot that they had stashed the catheters, so some expired. Through a successful 5S event, we increased our providers’ confidence that the product would be there when needed, while also significantly reducing supply expenses and wasted staff time searching for items.

    5S methodology

    Phase 1: Seiri (sorting and discarding)

    The goal for this stage is to create an empty and clean work area. Make sure to take a before photo.

    • Step 1: Remove all waste or anything that doesn’t need to be in the room or space. Trash, donate, repurpose or sell anything not needed.
    • Step 2: Move items you’re not sure of into either the center of the room or another room temporarily. If you are not 100% sure the item needs to go back in the area, then leave it out of the space for now. 

    Phase 2: Seiton (systematic arrangement)

    Focus on organizing and arranging items in a space for optimal access.

    • Step 1: Determine ideal item/equipment placement based on the frequency of use and who is using it. Place more frequently used items closer to their end-user. For example, exam room drawers were arranged with the most frequently used items in the top drawer, those less so in the second and so forth. Then standardize this across all exam rooms and locations, which saves time and frustration for staff and providers who rotate through these spaces.
    • Step 2: Calculate minimum and maximum quantity (PAR levels) needed by item type, used across the practice, specific location or room over a period of time.
      • Minimum safety PAR level should be calculated by multiplying the average daily usage times by a number of days (perhaps 14 days) that will provide sufficient quantity for your patient volume. Going too lean can risk an outage, causing providers and staff to quickly lose trust in the system. You can always adjust this quantity as the practice evolves.
      • Formula for calculating reorder PAR level: average daily inventory used over the last three to six months times lead time in days to receive replacement order plus minimum safety quantity. For items used across multiple exam or procedure rooms, divide the total utilization by item type by the number of associated rooms to get your target number for individual room stocking, adjusting for higher-volume spaces.
    • Step 3: Visually hard-wire quantities using different sizes of containers according to quantity to reduce both over-ordering and understocking. Use different color containers to group similar and/or differentiate between items that could be mistaken for each other.

    • Step 4: Label containers, shelves, drawers and cabinets (on the outside) for quick item identification. In supply rooms, noting item name, style or size type, and re-order number can save hours of staff time. While a barcode system could also be implemented, it may not make sense depending on the size of your practice. This is where the next set of tools comes in with standard work.
    • Step 5: Use Kanban (Japanese for “card”) tool as visual cues to signal supply reorder point and minimal safety quantity. Kanban cards should contain re-order/re-stocking information such as vendor name, item type, item skew number and typical quantity reordered (such as one box of 10 units vs. 10 individual units).
      • Yellow card: Place at the standard reorder point.
      • Red card: Place at the minimal safety level to signal that if the item is not ordered immediately, there could be a delay impacting care.

    Phase 3: Seiso (shining)

    Maintain a clean and organized environment. Once you have created an optimally arranged workspace, make sure you have a maintenance process in place.

    Figure 2 provides an example of converting an ASC cluttered equipment garage into an organized garage with “labeled individual garage stalls.” This allowed team members to quickly identify each item and replace consistently after use. To reinforce this, staff was trained to replace units immediately after use and implemented a quick garage checklist to ensure all items were in correct location each day.

    • Step 1: Define necessary actions, such as cleaning, restocking, equipment replacement, etc., that should be done daily to maintain the environment.
    • Step 2: Designate responsibilities to job role or individuals. This is a great opportunity to work together with the team to create aligned standard work such as daily opening and closing responsibilities.
    • Step 3: Conduct training for impacted team members to reinforce changes.

    Phase 4: Seiketsu (standardizing)

    Standardize changes to ensure they are followed and to assess for any needed adjustments.

    • Step 1: Hard-wire with standard work to increase consistency of outcomes. One example could be implementing a daily 5S checklist for the associated area to reinforce goals with the team to maintain an organized environment.
    • Step 2: Audit the area frequently using a 5S audit tool to uncover any abnormalities. This task can be delegated to a team member for even more engagement.
    • Step 3: Determine root cause(s) of abnormalities. Is it a training issue or does the process need to be adjusted? Often, PAR levels will need to be adjusted due to changes in patient mix, procedure mix, room use, etc.

    Phase 5: Shitsuke (sustaining)

    As with any change management initiative, sustaining changes often proves challenging. Developing a broader system can be helpful.

    • Step 1: Assign a process owner accountable for metrics and process review on a regular basis.
    • Step 2: Address repeated non-compliance via re-training and/or performance management, if necessary.
    • Step 3: Implement a visual monitoring tool such as a 5S dashboard to track financial or quality changes in high-level metrics that could signal process variation.

    Measure your results

    Since implementing any process improvement initiative requires focus and time, it is important to always quantify financial and quality outcomes so you can celebrate successes with your team and set the stage for future changes with the rest of the organization. Fortunately, 5S events drive changes that easily quantify financial savings by creating savings around supplies or staff/provider time. Some financial examples include: decrease in supply expense/volume (wRVUs, arrived visits or procedures), increase in volumes per full-time equivalent staff or provider or decrease in staff expense per a given task due to reduced movement or rework. Additionally, process quality measures can also be tracked, such as first-time-quality, frequency of over or under-stocking, or reduction in errors.

    It is important to define which measures you are focusing on in advance so that you can capture pre- and post-event data to celebrate with your team and leadership, setting the stage for support of future process improvement initiatives and even greater engagement and success!
    Successful 5S implementation can serve as a launching pad for your process improvement journey and transform your organization by creating a culture of innovation and engagement. So, let’s 5S!

    Adrienne Lloyd

    Written By

    Adrienne Lloyd, MHA, FACHE

    Adrienne Palmer Lloyd, MHA, FACHE, worked as a healthcare executive for more than 20 years, including 10 years at Mayo Clinic in chief executive and director-level roles and seven years at Duke Health System, serving as the chief administrative officer for Duke Ophthalmology and Surgical Practices. She believes in embracing change and has helped identify and develop physician leaders, merge opposing cultures, and capitalize on diverse strengths to build successful, integrated teams. She founded Optimize Healthcare to help other healthcare executives and physician leaders reshape their organizations. Her signature Day Zero Blueprint™ program is helping transform leaders and organizations as they shift the belief that they need to do it alone or sacrifice what is important to them. She incorporates her training as a John Maxwell Certified Coach and Lean/Six Sigma expert to provide program participants and audiences with time-saving strategies and templates.

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