T eamwork Is Key for Improving Performance

1 35 Teamwork Is Key for Improving Performance The healthcare industry has discovered the value of teamwork in Improving Performance in the past few years. Traditionally, the healthcare workplace has been organized hierarchically, with physicians at the apex and other workers supporting the orders given by the physician in the interest of the patient. This system seemingly worked well for decades, particularly as the medical knowledge base expanded expo-nentially, creating increasing specialization and highly esoteric medical practice. Subspecialties have allowed improved scientific understanding of disease entities, but at the same time the relatively arcane knowledge base required in each of the subspe-cialties has mandated that patient care become an interdisciplinary effort.

2 Although the traditional method of having a single captain of the ship, usually the physician, once prevailed in delivering care to patients, healthcare processes have become increas-ingly a matter of teamwork, with multiple staff members accountable for ensuring safe and high-quality care. Thus improvement initiatives must be interdisciplinary if they are to succeed, with each team member participating equally. Choosing a Project One of the concepts we discuss in this book is using work systems that involve lean process management and six sigma project measurement systems. Using these approaches entails consideration of several factors in project selection. It is conceivable that a project may make big improvements in quality and productivity that have absolutely no impact on net profit.

3 A lean six sigma project often relies on the theory of constraints articulated by Goldratt 1 in the 1990s to determine which projects to pursue. Every organization has constraints that usually come in many forms and may actually have a useful purpose. Goldratt proposed using the following rules when a process has a resource constraint: 1 1. Identify the system s constraint(s) . Review the process to determine if any bottlenecks are present. Managers often consider bottlenecks to be a negative 2 Teams in Healthcare Performance Improvement 3510/6/09 2:52:56 PM10/6/09 2:52:56 PM Jones and Bartlett Publishers, LLC. NOT FOR SALE OR CHAPTER 2 Teams in Healthcare Performance Improvementfactor constraining a process, but a bottleneck may be a competitive advantage for a company.

4 For example, an expensive piece of equipment, such as a positron emission tomograph, may be a bottleneck for a hospital, but the purchase and operational cost of the machine may make it a competitive advantage in a given market. Thus the bottleneck is actually a benefit for the organization, and upstream push and downstream pull are the areas in which efforts may be concentrated for Improving the process. 2. Decide how to exploit the system s constraint(s) . Projects should minimize waste related to the constraints. For example, if the constraint is market demand, then the project may involve 100% on-time delivery to optimize customer satisfac-tion. If the constraint is a machine, as noted in step 1, the focus of the project is usually on reducing setup time, eliminating waste and rework, and optimiz-ing run time.

5 3. Subordinate everything else to the decision made in step 2 . Projects that maxi-mize throughput of the constraint provide the greatest payback, and the selected project will eliminate waste from downstream processes and steps ( , once the constraint has been used to create something, wasting the output because of a process glitch is highly counterproductive). If downstream processes are already functioning efficiently, then upstream process steps that ensure an adequate supply of resources will be the next target for a project. Slack resources are often the issue for upstream process steps, whereas either slack resources or uniform output flow tends to create problems downstream. 4. Elevate the system s constraint(s). Elevate the constraint means lift the restric-tion.

6 Often, the projects completed in steps 2 and 3 eliminate the constraint. If the constraint continues to exist after performing steps 2 and 3, then the next effective approach may try to identify projects that provide additional resources to the constraint, like purchasing additional equipment or hiring additional workers with particular skills. 5. If, in the previous steps, a constraint has been broken, go back to step 1. If the constraint has been elevated but process output remains suboptimal, the pro-cess may not have been properly characterized, and the next approach is to review and remap the entire process, with the goal of identifying steps that were left out of the initial evaluation. Thus the task of project selection begins again.

7 Another, more traditional, approach to project selection involves Pareto analysis, known to many as the 80-20 rule. The basic principle states that 80% of the prob-lems in a process are caused by 20% of the possible sources. Pareto analysis involves identifying all the possible causes of variation or problems in a process, quantifying the number of times each cause occurs, and then graphing the results or placing them in a table sorted by the largest number. A sample Pareto analysis is illustrated in EXAMPLE 3610/6/09 2:52:57 PM10/6/09 2:52:57 PM Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. Choosing a Project 37 Example Pareto Analysis The laundry service at CleanCloth Hospital cycles bed linens once every 6 hours for the medical-surgical unit, using Machine C, which is dedicated to the medical-surgical linens.

8 The linens need to be back on the floor 12 hours after they have been removed, that is, the laundry team must launder the linens within 6 hours so that they are dried, folded, and returned to the floor within 12 hours. The upstream process consists of environmental services removing the bed linens, putting them in the proper container, and transporting them in batches to the laundry, where they are sorted to ensure that the linens are matched with Machine C. The downstream process entails drying, folding, and delivering the linens to the appropriate closet on the medical-surgical unit. Over the past 6 months the manager of the laundry service noted that approximately of the medical-surgical linens are late returning to the unit, which has required using supplemental linens at added cost.

9 The manager studied the process through 300 cycles and collected the number of incidents of errors at each step upstream and downstream from the constraint (Machine C), with the following results. CauseProcess PositionFrequency of DefectsPercent of SampleLate collection of bed transport to time and folding to medical-surgical The traditional method of displaying these data is a bar chart, as follows: 0123456 Late transportDelay deliveryLong sortLate collectionLate 3710/6/09 2:52:57 PM10/6/09 2:52:57 PM Jones and Bartlett Publishers, LLC. NOT FOR SALE OR CHAPTER 2 Teams in Healthcare Performance Improvement The Pareto analysis in EXAMPLE clearly indicates that upstream processes are the most likely culprits for intervention, and both environmental services and laundry will initiate projects to improve that part of the process.

10 As project parameters are being examined, several issues must be considered: Importance to the organization s stakeholders Impact on a specific Performance measure or set of measures Regulatory requirements Alignment with the strategic plan Ability to perform the project in a reasonable time Technical feasibility of the project, given existing resources Reproducibility in other departments or divisions Available financial and material resources Human, financial, legal, and organizational risks Cultural readiness for dealing with results Once projects are determined, the next step is to select an optimum team for developing improvement initiatives. Team Development Team formation and function tends to follow four specific stages: 1.