Going to Gemba

When did you last walk the floors of your OR? Combined with the Greening the OR checklist, it's a valuable exercise that can establish a baseline and identify opportunities for improvement.

By iqbal mian on January 19, 2017

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When I studied supply chain and operations management during my undergraduate years, there was a simple story I’ll always remember from Michael Dell (yes, the man who created Dell computers, which led to the eventual “Dude, you’re getting a Dell” commercial!). Dell had received customer complaints that hard drives were failing in their personal computers. Rather than blaming technicians on the service and assembly line, Dell himself walked the floors and watched the number of times hard drives were physically handled before being finally installed into their machines. That number was more than 30. After making adjustments to the service and assembly line, that number was reduced by more than half and consequently, the failure rate was reduced by more than 20 percent.

That incremental change taken by Dell helped prevent future dissatisfied customers. Arguably, the outcome couldn’t have happened without first going to the source of the work and conducting observations. This specific interaction in the process-improvement world and Toyota Production System philosophy is known as gemba, which in Japanese means “the source.”

While this terminology is well-versed and well-practiced in the automotive industry, don’t be surprised to find it taking off in the service industry in hospitals and health care—and why not? Going to gemba is essential to sustainability and the patient care experience in linking the natural environment and the built environment together, along with the processes that collide between employees and patients in various service lines. It’s so crucial that progressive health care organizations such as Virginia Mason in Seattle created an institute in 2012 around lean process improvement in the pursuit of zero defects, zero infection rates and 100 percent satisfaction. This vision didn’t come from an engineer or an external consultant, but rather Virginia Mason’s own CEO, Dr. Gary Kaplan, who reminds his staff that it is about quality outcomes in patients and people.

Consequently, going to gemba was the very first thing I did on every initiative and project when I was a lean leader for sustainability at Ascension Health/Wisconsin Ministry Market. This simple practice made looking at data so much more real, and allowed me to respect barriers and issues by physically witnessing the “what” and “how” in the health care space. It also taught me a very humble trait: to treat people with respect. When you spend time observing nurses in the emergency department before doing a redesign or learning how patient room turnover occurs with environmental services staff, you begin to understand how certain aspects of the job can make it more difficult for those on the front line. This is why lean practitioners advise focusing on process, not people, when issues arise, since it may be upstream or downstream sources that are the true culprits.

Taking It to the Floors

Practice Greenhealth’s Greening the OR Initiative (www.PracticeGreenhealth.org/initiatives/greening-operating-room) documents extensive savings by health systems such as Advocate Christ Medical Center in Oak Lawn, Illinois, whose participation yielded $400,000 in savings and five tons of waste diversion from reprocessing, and St. Mary’s Hospital in Green Bay, Wisconsin, which saved $10,000 by reducing 5,400 pounds of regulated medical waste through its fluid management system. Recently, we wanted to evaluate similar opportunities for savings and improvement by conducting a baseline of the Greening the OR checklist at two pilot sites: St. Elizabeth Hospital in Appleton, Wisconsin, and Howard Young Medical Center in Woodruff, Wisconsin. How can one start such a baseline? That’s right—by first walking the floors and going to gemba.

The assembled team included members of the local green team, such as Mike Hofmann, director of perioperative services; Steve Kappell and Rob Johnson from facilities management; Patricia Comperini and Rachel Loduha from environmental services; and Zach Eichhorst, an intern with the department of performance excellence. “Greening the OR is important because it’s a large source of waste for the hospital,” said Hofmann. “Every day, we get a truck full of supplies for procedures, and at the end of the day, that would go out as garbage. I’ve been here for 20 years … the nurses and techs on the team wanted to reduce our impact on the environment early on.”

The Greening the OR checklist features detailed practices in waste reduction and prevention, environmentally preferable purchasing (EPP) and the built environment. Armed with a camera phone and notepad, the team observed day-to-day functions, making their best attempt to minimize disruption to patient care. A few ground rules were set prior to the gemba walk, revolving around safety and privacy. Even though we were internal employees with a clinical champion, we also respected the caregivers and patients flowing through this very sensitive space. With that said, the team went room by room and area by area over 15 ORs, and made observations with respect to items on the checklist.

goingtogemba2Within the checklist area of waste reduction and prevention, containers near the point of use were observed to recycle clean, rigid plastics; blue wrap; soft plastics such as overwraps; and batteries with clear labels. The process of diverting pre-incision, nonpharmaceutical waste from regulated medical waste streams into clear bags for noninfectious waste disposal was seen to function well. Because of the various materials and streams, best practices in visual management (labels) were observed being implemented by clinicians to ensure proper disposal. This practice, surprisingly, came from empowered clinicians who felt their connection to stewardship.

Technologies such as fluid management systems were in place, and extra observations around overall cleanliness were witnessed. The floors and disposal areas were pristine, with accolades going to the EVS team. Despite third-shift cleaning practices not being observed during this particular walk-through, clinicians acknowledged their appreciation.

Moving into other categories such as EPP and the built environment, the procurement side of the OR was observed easily. From ENERGY STAR equipment to reusable grounding pads and reformulated OR kits, the department was very conscious about mitigation. Reusable gowns and covers for Mayo stands and back tables weren’t fully implemented, but clinicians explained that the benefits and infection prevention aspects were being fully investigated. It was specifically helpful to see sterilizers and autoclaving, and to imagine water conservation possibilities. Moreover, at the request of clinicians on the floor who were curious about the benefit of occupancy sensors, we placed data loggers in rooms to collect a month’s worth of occupancy data, such as lighting, humidity and temperature. The data revealed that an easy $1,500 a year could be saved through the practice of turning lights off during low occupancy alone. Combined with LED lights and occupancy sensors, the savings figure would be even higher.

Along with the financial opportunities and overall benefit of conducting a baseline of the Greening the OR checklist, the team was happy to learn how widely the pilot facilities were allowing their practices to be scaled to other sites within the system. Furthermore, OR directors were filmed asking why they thought this initiative was important. Their genuine answers reflected why they were caregivers in the first place, and why they took the oath of “First, do no harm.” This video (https://youtu.be/1Sp7JHH4QlA) played at regional management meetings and was viewed by senior leaders who felt pride in reflecting a culture of improvement.

The takeaways in going to gemba in this particular application—conducting a baseline of the Greening the OR checklist—reiterated a theme I know well: No two gemba walks are the same, and you never know what you’re going to learn until you go to the source. The full checklist and reports generated on behalf of this walk created the starting point for the business case for big-ticket items like programming OR setbacks, procuring certain supplies and upgrading to LED lighting, all of which contribute to a more positive patient care experience, with the byproduct of triple-bottom-line savings. So, there you have it: Go to gemba and observe for yourself what is happening on the floors of your own hospital.