October 2011 Vol 94 No 4 • AORN Connections | C7doi: 10.1016/S0001-2092(11)00964-1© AORN, Inc, 2011

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Using lean to build high performing teams

When Kathryn Uran, MS, RN, took on the perioperative services area in her role as associate chief nursing officer within the

Denver Health and Hospital Authority System in Denver, Colo., she knew her skills in building and coaching high performing teams would be put to good use. Among the perioperative leadership team she found unclear role definitions leading to duplicated work and confusion among staff members about who to report to. She also found mismatched and overloaded perioperative service teams and a high-rate of perioperative staff nurse turnover. Uran and Chief Nursing Officer Kathy Boyle, PhD, RN, decided to implement a Lean Rapid Improvement Event (RIE) targeted toward improving this perioperative service structure. “Lean is the best quality model I have ever worked with. It’s an enterprise wide solution,” noted Boyle, who served as executive sponsor of the Perioperative Value Stream that this RIE was part of.

Denver Health is a 477-bed, level 1 trauma center that is well known for its system-wide implementation of Lean principles for continuous improvement. Since 2005 this implementation of Lean principles has led to more than $114 million in savings for the organization and led it to become the first health care organization to win the Shingo prize for operational excellence. Both Uran and Boyle spoke at AORN’s Leadership Conference in June to share their implementation of this RIE and other Lean work to reduce the “muda” (waste) at Denver Health. “Waste is viewed as disrespectful to people within the Lean principle of transformation” and it has no place in health care, Boyle stressed.

Getting rid of the “muda” In preparation for this Lean RIE for improving

Denver Health’s periopertive service structure,

Uran took six months to interview staff members, evaluate competencies and understand where waste could be addressed. She identified non-standard competencies, unclear management roles, a lack of synergy among perioperative team members and overall workforce dissatisfaction. Armed with this knowledge she worked with the Perioperative Value Stream Steering Committee to build the RIE team and begin this Lean project, making sure to include a good cross-section of roles and personalities for the team. She also included someone from outside of the department who could take a fresh look and question what had become the status quo for the team. Lean RIEs span just one week, taking a focused approach each day to tackle important issues in working toward a target state for improved and more efficient work.

Day 1: establish reason for action Uran’s team knew going in to this RIE that

there was inconsistent staff scheduling, a lack of synergy between team members and the need to further standardize staff competencies. We started by getting more clear on our reason for action, Uran explained. “We had to ask each other why are we here, why are we making these changes,” she said, noting the importance of open communication so every member of the RIE team feels safe in sharing their perspective. “What drove it home for the group was one of our surgeons saying he didn’t mind seeing new faces in the OR, as long as he could see them again,” Uran said. “Through this process we all recognized the detrimental effect high turnover and unclear management roles were having on perioperative team members.”

Day 2: Outline initial stateOnce establishing a reason for action, day 2 of

this RIE was dedicated to putting down on paper the current state of the service structure. For this Uran and her team covered a wall in butcher paper and wrote down what was preventing

COnDUCtinG a lean RapiD impROvement event at DenveR HealtH meDiCal CenteR HelpeD peRiOpeRative leaDeRs finD aReas fOR leaDeRsHip DevelOpment anD seRviCe stRUCtURe impROvement

By Carina StantonSenior News Editor

C10 | AORN Connections

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surgical teams from performing at a higher level. Some of these factors included: gaps in communication, inconsistent staff scheduling and unfilled service leader positions. “In this process it is important to really spell out the causes for this initial state,” Uran explained. For example, to better understand the reasons for inconsistent staff scheduling the team noted problems with the scheduling process, such as the schedule being released late and not being consistent.

Day 3: establish target stateOnce the team established specific problems and

areas for improvement they outlined their ideal elements of a target state—where they want to be with service structure. These elements included: specialty teams being grouped and optimally sized, all positions filled with 90 % retention targeted and alignment of service teams to service blocks.

“We then defined roles for each staff member to facilitate this target state so we could get buy-in and sign off from each staff member, including physician champions,” Uran noted. She also said that day 3 of an RIE project is often dedicated to testing.

Day 4: Develop a completion plan To outline clear solutions the team created a

solution approach chart that outlined an action, such as expanding the perioperative preceptor program, and getting a corresponding result. For this RIE metrics were focused on a decrease in the patient occurrence reports and increase in operating room utilization.

Day 5: Report what you learnedOn the fifth day the team reported on the RIE in

a forum to summarize the events of the RIE and the plan for results. Following this RIE, Uran and Boyle noted more efficient team structure, team engagement and communication. Staff members are speaking up more, within the surgical setting and in staff meetings, Uran observed. “When you allow team members to speak up and be heard it opens to door to more engagement, more dialogue and a feeling of safety, which can also strengthen a culture that support good patient outcomes.”

additional resourcesDenver Health Lean Systems Improvementdenverhealth.org/AboutUs/LEANSystemsImprovement.aspx