Lean Thinking for Long-Term Care
Contents
Executive Summary ........................................................................................ 3
What is “Lean Thinking?” ................................................................................ 4
Overview...................................................................................................... 4
How lean works ........................................................................................... 4
Lean for Long-term care ................................................................................. 6
Do I need Lean? ............................................................................................. 6
List care vs. Lean care ................................................................................ 7
Who practices Lean in LTC? What are the results? ................................... 9
Where Do I Start? ......................................................................................... 10
Step 1: Waste identification...................................................................... 12
Step 2: Problem solving ........................................................................... 14
Step 3: Process mapping .......................................................................... 16
Voice-Assisted Care ..................................................................................... 19
What it is.................................................................................................... 19
Why it is Lean............................................................................................ 19
How everyone benefits.............................................................................. 20
Appendix 1: History of Lean and examples from service industries ............ 23
Appendix 2: Problem solving storyboard template ....................................... 26
Appendix 3: Identifying residents who did not have a BM in last three days 27
Appendix 4: Documentation of I&O record .................................................. 28
Appendix 5: Skin observation ...................................................................... 29
Appendix 6: Documentation of vital signs.................................................... 30
Appendix 7: Unit meal intake report............................................................. 31
Appendix 8: Intake and output report............................................................ 32
Appendix 9: Unit weight report..................................................................... 33
Appendix 10: Summary of process flow maps............................................. 34
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Lean Thinking for Long-Term Care
Executive Summary
The long-term care industry wastes billions on unnecessary paperwork,
searching for people, time in meetings, data entry, preparing for audits, and
more. “Lean Thinking” is a disciplined approach that has removed billions in
cost from a wide variety of industries, from consumer services to healthcare.
Leading long-term care organizations are taking notice.
The bottom line: if you’re relying on paper or data entry-intensive
technologies like kiosks or PDAs for delivery of care, your operating costs
and reimbursement effectiveness are most likely double digits away from
where you could be.
Pull large dollars out of your operations. Forward thinking long-term care
organizations are Leaning-up processes and applying voice-assisted care
technologies that have been successfully applied in the supply chain industry
to pull significant dollars out of their operating costs. Leaders see:
• Increased reimbursements. Church of God increased reimbursement
effectiveness and saw Case Mix Index (CMI) go from 1.27 to 1.34 in just
seven months.
• Reduced nurse overtime. Kendal at Longwood reduced nurse
overtime by more than 50%.
• Elimination of paperwork.
Each of these organizations was using paper to chart ADLs and burning a lot
of cash as a result. They all took a Lean approach to long-term care,
overhauled processes, implemented voice-assisted care, and have since
reaped significant benefits.
Ready to pull dollars out of your operations? This paper describes how
you can take a Lean approach to process improvement and reduce dollars
wasted on unnecessary paperwork, steps, searching and more…with voice-
assisted care. Your teams will work smarter, faster, and with more focus on
resident needs.
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Lean Thinking for Long-Term Care
What is “Lean Thinking?”
Overview
A concept pioneered after the World War II by Toyota, Lean is a disciplined
approach to continuous quality improvement that has transformed dozens of
industries, from manufacturing to banking, energy to logistics, consumer
services to healthcare. For more information on the history of Lean and how
it is applied in service industries, see appendix 1.
Because lean is new to the long-term care industry, there are many
opportunities to use Lean to improve quality of care and reduce costs. Lean
involves evaluating how care is delivered and rethinking processes to
eliminate “waste” like extra steps, paperwork, searching for people, data
entry, preparing for audits, and much more. Unlike other quality programs,
Lean emphasizes respect for people, where an integrated approach for care
delivery is vital for success.
How lean works
Lean Thinking helps energize teams to work smarter, faster, and with true
focus on customer needs. This paper will offer several practical ways to
map current unhealthy processes and help you work towards healthy
processes.
Lean thinking is a way of
streamlining the patient
journey and making it
safer, by helping staff to
eliminate all kinds of
waste and to treat more
patients with existing
resources. Originally
developed by Toyota, it
is now being
successfully applied in Over the past 20 years, practitioners of Lean have used a variety of tools to
hospitals across the make processes healthy. There are dozens in the Lean toolbox, including:
world.
• 5S • Kaizen events • Reporting &
Dan Jones, Chairman, • Continuous flow • Kanban for supplies communications
Lean Enterprise • Cycle time • Leveling • Runners
Academy • Document tagging • Measurement • Six Sigma
• Error proofing techniques • Standard work
• Goals and outcomes • Filing systems • Takt time
• Goal card • Physical layout • Value stream maps
• Cases • Pitch • Visual controls
• Interruptions and • Predictable output • Waste identification
random arrivals • Problem solving • Work load balancing
• Just-in-time • Process mapping
• Pull systems
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Lean Thinking for Long-Term Care
They always say time Knowing when and how to use all these tools can be a full time job!
changes things, but you Fortunately, most of the tools are simple to use and don’t require special
actually have to change skills or technology. We advocate starting with three, and you don’t have
them yourself.
to be an expert to use them
Andy Warhol
• Waste identification
• Problem solving
• Process mapping
When these three are integrated, you’ll have powerful ways of energizing
teams and transforming your clinical environment.
The tools do not require special technology. You have all you need to get
started with the collective brainpower in your organization, along with pencil
and paper. We’ll go into more detail regarding the ‘how to’ steps when we
describe how leaders in the long-term care industry are applying these tools
today.
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Lean Thinking for Long-Term Care
Lean for Long-term care
You can't change what Do I need Lean?
you don't acknowledge.
In the long-term care environment, Lean is about reducing the time (and
Dr Phil cost) it takes to provide quality care that responds to residents’ needs. How
efficient is your team at converting needs to quality care? Do any of the
following sound familiar?
• “I spend way too much time going through flowsheets I can barely read
in order to generate unit reports” (Nurse)
• “I’m in reactive mode: It’s hard for me to identify changes in a resident’s
status…before they become real issues” (Nurse)
• “I’m frustrated when I have to leave a fallen patient, and run around the
building to find help” (CNA)
• “I spend way too much time doing paperwork and not enough time with
residents” (CNA)
• “Missing ADL information drives me crazy when I’m completing my
MDSs (Assessment Coordinator) “How can we do better with our
reimbursements?” (CFO)
• “How can we reduce the number of falls?” (VP Clinical)
• “Why is it taking so long to complete MDSs?” (Exec. Director)
• “Why do I have to wait for the quality indicator report to know this
information?” (Director of Nursing)
If you can relate to any of these common problems, chances are Lean
Thinking can help you. Each of the problems described above relate to
problems with processes, or activities that add no value, in the mind of your
customers—your residents. “Non value-add activities are usually symptoms
of a problem within a process.1”
Problems with processes have their costs. A study conducted by United
States General Accounting Office found that MDS reports are inconsistent
(contain errors) when compared with other medical records, on average, in
36% of cases for the following subset of MDS items:2
1
Hadfield, Debra, RN MSN; Tom Fabrizio; Shelagh Holmes, RN; and Don
Tapping. Lean Healthcare: Implementing 5S in Lean or Six Sigma Projects.
MCS Media, Inc. 2006; p.13.
2
ABT Associates, Inc. as quoted in GAO-03-187 Report to Congressional
Requesters “Nursing Homes: Public Reporting of Quality Indicators Has
Merit, but National Implementation is Premature”
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Lean Thinking for Long-Term Care
From a Lean perspective, these errors lead to wasted time spent in
reconciling MDS with medical records and other more serious
issues…including the opportunity costs of not being reimbursed at the right
You can observe a lot by level!
watching.
Even simple errors can be costly. Improperly completed flowsheets can
Yogi Berra impact ADL scores, RUG levels, MDS filings, and ultimately reimbursement
dollars—which can really add up. Consider the impact of recording a 1-
person assist when a 2-person assist was required:
List care vs. Lean care
Today, most of the long-term care industry uses a list-based approach. List
thinking causes us to think linearly about processes, rather than
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Lean Thinking for Long-Term Care
systematically.3 In other words, and especially in long-term care, we fall into
a trap of thinking, ‘if we just get this list of items done everything will be OK.’
The process revolves around forms that cascade down from reimbursement
vehicles to care plans. Check list-based care can lead to unhealthy
processes. For example, if a care plan needs to be changed, a waterfall of
communication activities must occur, from updating clinical software, to
manual updates to care plans to manual updates to flow sheets to verbal
communication to staff of a change. These minutes of non value-add time
can add up quickly.
Lean Thinking takes check list-based processes apart piece by piece, and
will help you quickly identify non value-add steps and ways to eliminate them.
3
Richmond, Barry: An Introduction to Systems Thinking. 1995, ISEE
Systems, Inc. http://www.fi.muni.cz/~xpelanek/IV109/IST.pdf
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Lean Thinking for Long-Term Care
Who practices Lean in LTC? What are the results?
Lean is a new concept in the long-term care industry. Early adopters are
We are not a product of
evaluating processes, identifying areas of waste, and solving some critical
what has happened to
us in our past. We have problems in their organizations—resulting in better care at lower costs:
the power of choice.
• Church of God increased Case Mix Index (CMI) from 1.27 to 1.34 in just
Stephen Covey
seven months. Church of God also reduced nurse and caregiver
overtime, eliminated almost all caregiver paperwork, and reduced the
time spent by caregivers on end-of-shift reporting.
• Kendal at Longwood reduced nurse overtime by more than 50%,
reduced time spent on paperwork by 25 minutes per nurse per shift and
27 minutes per nursing assistant per shift. Kendal at Longwood also
replaced end-of-shift meetings with audible reports and saved more than
15 minutes per nurse per shift and 30 minutes per nursing assistant per
shift.
Once processes are understood, improved, and streamlined, there are a
variety of technologies available to take performance to the next level. For
each of the scenarios above, voice-assisted care was chosen as part of the
solution and will be discussed in a later section of this paper.
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Lean Thinking for Long-Term Care
You can analyze the
past, but you have to
Where Do I Start?
design the future. As discussed earlier, there are dozens of Lean tools available, and one could
make a career of putting them to practice. In our experience, we’ve found
Edward de Bono the three tools below to be simple and powerful ways to get started:
Step Lean principles4 Lean tool
1 Manage the business backwards from the customer Waste
(resident) definition of value – not forwards from your identification
assets and your organization
2 Build a management system to develop, sustain, and Problem solving
improve processes
3 Create end-to-end primary processes to design, deliver, Process
and support this value – with minimum wasted effort and mapping
time – along with the support processes to enable them
Next, assemble a team with a variety of viewpoints, from a variety of
functions, and with varied experience levels in the organization.
Using Lean tools involves a lot of brainstorming, and you’ll want to make sure
to avoid ‘linear thinking.’ Linear thinking ignores interdependences of
processes in your complex environment. System thinking is the opposite of
linear thinking and involves connecting disparate ideas and seeing patterns
in your web of processes. When groups are small or people think alone, they
often fall prey to linear thinking.
The more diverse your team is, the less likely you’ll see linear thinking, and
the better the outcome will be.
4
Source: http://www.leanuk.org/articles/LSS_2004/Plenary_Jones.pdf
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Lean Thinking for Long-Term Care
Tips for good brainstorming
• Define the problem you want solved clearly, and lay out any criteria to be
met.
• Keep the session focused on the problem.
• Ensure that no one criticizes or evaluates ideas during the session.
Criticism introduces an element of risk for group members when putting
forward an idea. This stifles creativity and cripples the free running
nature of a good brainstorming session.
• Encourage an enthusiastic, uncritical attitude among members of the
group. Try to get everyone to contribute and develop ideas, including the
quietest members of the group.
• Let people have fun brainstorming. Encourage them to come up with as
many ideas as possible, from solidly practical ones to wildly impractical
ones. Welcome creativity.
• Ensure that no train of thought is followed for too long.
• Encourage people to develop other people's ideas, or to use other ideas
to create new ones.
• Appoint one person to note down ideas that come out of the session.
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Lean Thinking for Long-Term Care
Step 1: Waste identification
The Waste Identification tool helps your team identify where to focus first.
Set up a brainstorming session and make two lists:
• Activities that are essential for quality care
• Activities that add cost or time but do not add value
Having trouble getting started? Practitioners of Lean typically divide waste
into eight categories:
Lean “Wastes” Definition Examples in Long-term care:
1. Over- Producing a service • Pills given early to suit staff schedule
production prior to it being required
• Treatments not done on schedule to balance equipment workload
2. Waiting Unnecessary delays • Nurses waiting to compile reports because flow sheets are completed at the
end of a shift
• Nurses waiting for changes in resident’s status that require attention
• Residents waiting for the care to which they are entitled because care plan
changes are not communicated
• Residents not receiving turning/positioning on time, increasing risk of
pressure sores
3. Excess motion Movement of people, • Searching for staff when help is needed with a resident
paper, equipment, • Searching for charts
information that does
• Searching for supplies or equipment
not add value
• Carrying paperwork to the nurse’s station
4. Transport Excess movement • Transporting a resident to PT/OT/ST early/late
• Moving equipment early/late to the wrong area
5. Over- Putting in more effort • Tying up staff in end-of shift meetings
processing than is required
• Making ADL notes all day and waiting until the end of the shift to copy to
flowsheets
• Compiling paper documents to make reports
• Writing vitals in a notebook, transferring to a central board, and entering into
a database
• Preparing for state surveyors
6. Inventory Excess stock, work • Printing and stocking forms
piles, and supplies • Obsolete charts, files, equipment
• Duplicate supplies
7. Mistakes Anything you have to do • Wrong or missing ADL information
to correct errors • Wrong assist level recorded on a transfer
• Copy-cat charting
8. Unused Underutilizing the • Tying up staff time doing paperwork
creativity talents of staff
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Lean Thinking for Long-Term Care
Here are more examples of low hanging fruit:
Value-add activities
Value-add activities are things that residents and their families appreciate
and are willing to pay for.
• Care plans delivered 100%
• Timely responses to nurse calls
• Access to caregivers during shift changes
• Complete, accurate and timely paperwork
• Other factors that contribute to overall dignity, and quality of life
• More?
Non value-add activities
• Extra steps / travel time (e.g., deliver paperwork)
• Reliance on memory and tracking down/correcting related errors
• Stopping care to fill in flowsheets
Teamwork provides
superior motivation, • Searching for staff when help is needed
enhanced coordination, • Compiling information to make unit reports
improved problem • End-of-shift meetings
solving, and better
• Excess overtime
decision-making.
• Excess training time due to high turnover
James Womack, • More?
Father of Lean
When you reach 10-15 non value-add items, you’re off to a great start.
Finally, prioritize items by those that are causing the organization the most
grief in terms of staffing efficiency, cost, and compromised quality of care.
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Lean Thinking for Long-Term Care
Step 2: Problem solving
In Step 1, the team identified and prioritized the major areas in your clinical
environment that are ripe for improvement. Next, a problem-solving
storyboard will put a frame around each of the major problems you’re trying
to solve (choose 3-4 top ones). With its simple, single-sheet approach, the
storyboard will help you keep the team focused on a common goal.
The Education for Lean Healthcare Institute proposes the following
framework and pointers5:
Problem Solving Storyboard
Department Date
Team Name Team Members
#1 Describe the problem #2 Contain the problem
(Most important step!) Band-aid that may be needed until a
permanent solution can be
Be specific – how big?
implemented.
Increasing/decreasing? How long
has it been going on? How first
identified?
#3 Brainstorm and determine solutions
Gather data (from step 1), prioritize a processes to transform from unhealthy
to healthy, and build process maps (see step 3).
#4 Verify root cause
Find the root cause of your highest priority unhealthy process with which
everyone agrees. Next, clarify barriers in the way of implementing your
proposed healthy process (approvals, timing, budget, impact on others).
#5 Implement solutions #6 Verify effectiveness
List those from whom you need buy- Track solutions per the problem
in. What will you implement? When? description. Update training
Who? How measured? documentation for new employees.
A blank storyboard template you can photocopy is in Appendix 2.
5
Hadfield & Holmes, p. 103.
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Lean Thinking for Long-Term Care
Here is an example using one of the success stories for Lean in long-term
care mentioned earlier.
Processes are easier to Problem Solving Storyboard
fix than people.
William P. Thompson Team Name Team Members
Church of God Home CNAs
Director of Nursing
Nursing Assessment Coordinator
President & CEO
#1 Describe the problem #2 Contain the problem
Improve efficiency and quality of care Continue with paper-based
while improving financial performance processes until new system piloted.
Improve documentation of care to
enable correct reimbursement
#3 Brainstorm and determine solutions
Process maps (see next section).
#4 Verify root cause
Lack of point-of-care documentation leading to mistakes, omissions
Lack of instant access to care plans leading to inefficiencies
Breakdown of communications during shift changes
Paperwork causing overtime for nurses and nursing assistants
#5 Implement solutions #6 Verify effectiveness
Executive support gained for Paperless charting
overhauling processes, going Reduced searching/calling 75%
paperless, and implementing voice- CMI increase 7 points in 7 months
assisted care Annual savings $150,000
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Lean Thinking for Long-Term Care
Step 3: Process mapping
In the Problem Solving Storyboard, your team identified a problem,
determined root cause, and is ready to determine possible solutions (#3 in
the storyboard). Process maps are an easy way to get started.
Process maps show the sequence of events that produces an outcome.
Good maps show the time it takes for each step in order to make it easy to
understand the value of making changes. They are a helpful way of showing
the net effect of changing workflow.
First, map the current process:
1. Start upstream and note every step and the time it takes.
2. Note individual roles or sub processes, e.g., if nurses do one
function, and CNAs contribute another.
3. Move downstream, noting steps and time.
4. Finish with the desired value-add result.
Here is a very simple example showing a paper-based way for ensuring
documentation is complete, created once per shift for a 60 bed unit6:
In practice, many CNAs wait until the end of their shift to chart ADLs. So if
staff is behind, supervising nurses won’t know it until the end of the shift,
requiring the next shift to catch up on unfinished activities.
6
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted Care
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Lean Thinking for Long-Term Care
Next, highlight the steps that add no value. We recommend using three rules
of thumb to help determine if a step adds value:
• Is the step or activity essential for providing care? If so, it probably
adds value.
• If the resident was aware of a step, would he or she agree to paying for
it? If not, the step probably does not add value.
• If the step were eliminated, would the resident know the difference? If
not, the step is probably does not add value.
Finally, map a future state. Here is the same example showing a way to
ensure documentation is complete, created once per shift for a 60 bed unit.
All steps related to the management of paper have been removed, and staff
rely on voice-assisted care:
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Lean Thinking for Long-Term Care
Voice-assisted care leads to more complete ADL documentation because at
any time, you can click on reports to see how many ADLs are complete for
each resident or how many tasks are complete for each CNA. You do not
have to wait until the end of the shift to review flow sheets to see staff is
falling behind. So overall you have much better oversight of staff and can
improve allocation of resources.
ADL exception report: CNA progress report:
Shows completion of activites for each resident. Shows when CNAs are documenting.
In Appendices you’ll see more examples for the following:
• Appendix 3: BM report
• Appendix 4: Documentation of I/O record
• Appendix 5: Skin observation
• Appendix 6: Documentation of vital signs
• Appendix 7: Unit meal intake report
• Appendix 8: Intake and output report
• Appendix 9: Unit weight report
• Appendix 10: Summary of results from all process maps
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Lean Thinking for Long-Term Care
Voice-Assisted Care
What it is
Voice-assisted care helps organizations achieve better communication,
better documentation, and better quality of care by empowering caregivers
with voice. Caregivers wear lightweight headsets that enable them to hear
care plans, deliver care accurately, document care as it takes place, and
communicate with other staff more quickly in response to residents’ needs.
Why it is Lean
Voice-assisted care enables caregivers to multi-task, work faster, and more
efficiently—all of which help eliminate waste. Lean is about eliminating
waste to drive cost out and efficiency up. Examples include:
Source of waste How Voice-Assisted Care helps
Reliance on memory Caregivers say ‘care plan’ and get instant
access to a resident’s latest care needs.
Hard-to-maintain bedside cards are
eliminated.
Change communication When a care plan changes, caregivers are
notified the next time they request resident
information. No meetings or tracking down
ADL books for updates are necessary.
Flow sheet paperwork While they are with a resident, caregivers
document activities by responding to easy-to-
follow voice cues.
Steps Travel time back and forth to the nursing
station to gather forms or submit reports is
eliminated.
Searching Caregivers can use Silent Paging™ to rapidly
get assistance from others, or from the entire
staff, without leaving a resident.
Compiling information Staffing efficiency improves as less time is
to make unit reports spent on paperwork.
End-of-shift meetings Meetings are eliminated - that means more
time with residents without adding overtime.
Training time Voice cues guide caregivers through
documenting ADLs and incidents like falls.
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Lean Thinking for Long-Term Care
How everyone benefits
• Residents: by faster, more accurate delivery of the personalized
services they need, faster response to nurse call requests, and access to
caregivers during shift changes.
• Family members: with peace of mind knowing their loved ones are
receiving the care to which they are entitled.
• Administrators: with better care at lower operating costs, better
communication across staff, ease of responding to surveys, elimination
of overhead paging, quieter environment, more accountability.
• Directors of nursing: with instant access to staff through Silent Paging,
less time wasted preparing end-of-shift reports, quicker response to
surveys with on-demand reports, and a proactive approach to care.
• Nurses: with fast access to resident and unit reports; ability to identify
changes in resident status before they become issues; ability to
customize resident care information.
• Nursing assistants: with instant access to the latest care information,
notification of changes to a care plan as they occur, ability to get help
without searching, elimination of flow sheets to complete, and more time
with residents.
• Assessment coordinators: enjoy instant, accurate, legible, and
complete information on ADLs and other MDS items; complete
documentation with end-of-shift reports; and improved MDS accuracy.
• Senior executives: with improved reimbursements or CMI values
(where applicable), reduction of operating costs through increased
staffing efficiency, and lower risk.
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Lean Thinking for Long-Term Care
James E. Shearon, RN, BSN, MHSA
Jim Shearon is a seasoned expert in quality improvement, workforce
retention, person-centered care, and guideline-based care in the long-term
care industry. At Quality Insights of Pennsylvania, Jim perfected process
improvement models and helped a wide variety of clients drive new levels of
quality and cost savings. As a case mix specialist at HCR ManorCare, Jim
audited Medicare/Medicaid documentation and assisted nursing facilities in
completing MDS 2.0 documentation. As an RNAC, Jim implemented,
educated, coached, validated, and monitored the RAI Process. He was also
responsible for MDS, management of Medicare, PPS, and Medicaid to
ensure that all documentation met federal, state, and certification guidelines.
Jim received his bachelor’s degree in nursing from Clarion University of
Pennsylvania, RN certification from West Penn Hospital School of Nursing,
master’s degree in Health Services Administration from the University of
Saint Francis-Joliet, Illinois; and studied pre-medicine at California University
of Pennsylvania.
Roger Byford, President, Vocollect Healthcare Systems
Having pioneered and perfected the use of voice technology in industrial
settings for more than 20 years, Roger Byford is among the world’s leading
experts in applying voice to improve work. His breakthrough contributions
are used by hundreds of thousands of workers on six continents of the
world’s largest companies. Roger co-founded Vocollect, Inc., the global
leader in voice-directed distribution, and served as the company’s CEO for
fourteen years. He remains chairman of the company’s Board of Directors,
and is president of the newly formed subsidiary, Vocollect Healthcare
Systems, which provides better documentation, better communication, and
better care through voice technology for the long-term care industry. Roger
currently serves on the Information Technology committee for the National
Association for the Support of Long Term Care. Roger received
undergraduate and Master’s degrees in electrical engineering from
Cambridge University.
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Lean Thinking for Long-Term Care
About Vocollect Healthcare Systems
Vocollect Healthcare Systems, Inc., a wholly-owned subsidiary of Vocollect,
Inc., was founded by independent entrepreneurs as Adherence Technology
Corporation. Acquired by Vocollect in March of 2006, Vocollect Healthcare
Systems has become the leading provider of voice-powered point-of-care
documentation and communication systems for the long-term care industry.
About Vocollect
Since 1987, Vocollect Inc. has delivered proven performance improvements
in productivity, accuracy, cost reduction and worker satisfaction for mobile
employees. Vocollect Voice® literally talks people through their daily tasks,
replacing cumbersome lists and traditional data capture methods with hands-
free, personal voice dialogs. Hundreds of thousands of people on six
continents use Vocollect Voice to improve distribution operations every day.
Rapid return on investment has led to quick adoption by some of the world’s
largest companies; including General Motors, Nike, Wal-Mart, Pfizer,
Carrefour, Rockwell Automation, and many more.
Have More Questions?
Vocollect Healthcare Systems, Inc.
Phone (toll-free): 877-282-3456
Phone (local): 412-825-5400
www.healthcare.vocollect.com
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Lean Thinking for Long-Term Care
Appendix 1: History of Lean and
examples from service industries
History
More than a half century ago Dr. James Womack studied Toyota Motor
Company to understand the company’s success. He discovered the
overwhelming theme was more with less: less labor, less lead-time, less
defects, less space, less delays.
Womack was impressed with how Toyota placed special emphasis on factory
workers; noting that they had more to contribute than just muscle power.
“Teamwork provides superior motivation, enhanced coordination, improved
problem solving, and better decision-making.7” At Toyota, the foundations for
successful teams are training, compatible workflow, compatible organization
structures, understanding management, and patience.
In the mid-1980s, the Massachusetts Institute of Technology conducted a 5-
year study of 90 plants to compare Lean production with mass production. In
their best-selling book The Machine that Changed the World, the research
team, led by Womack, reported impressive results: “cars with one-third the
defects, built in half the factory space, using half the man hours.8”
What impressed the MIT team, and will likely impress you, is the simplicity of
Lean tools. It’s no wonder that industries everywhere have embraced them.
7
http://www.strategosinc.com/team_series.htm
8
Womack, James P., Daniel T. Jones, Daniel Roos: The Machine That
Changed the World: The story of Lean Production. Harper Collins
Publishers, 1991.
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Lean Thinking for Long-Term Care
Service industries using Lean
Given the success of Lean in the automotive industry, organizations
worldwide took notice, borrowed, and adapted the Lean tool box. Today,
dozens of industries, from manufacturing to banking—from energy to
logistics—from consumer services to healthcare– are using Lean to empower
workers, improve customer satisfaction, and drive out cost.
Even through its roots are in automotive, Lean is not just for manufacturing
companies. According to George Group, “as much as 30-50% of the cost in
a service organization is tied up in delays, mistakes and rework done to solve
problems for customers.” Using Lean techniques to improve workflow,
George Group’s average results across many service industries are
impressive:
• Speed up service delivery time by as much as 50%
• Reduce service costs by 30-50%
• Expand capacity by 20% -- without adding staff
• Improve quality to six sigma levels
Here are a few more examples of how service organizations are benefiting
from Lean today.
Pharmaceutical
A large pharmaceutical company used Lean tools to address overcrowded
labs, long cycle times, and poor customer service. Lean tools were used to
map processes, identify waste, improve flow, and implement continuous
improvement. As a result, lab backlog was reduced 80%, lead time went
from 25 to 16 days, and the project paid for itself in less than 6 months.9
Financial Services
If an idea isn’t a little A bank experiencing higher-than-expected traffic at branch offices asked
scary, it’s probably not
people to work overtime, thereby increasing costs and reducing quality of
much of an idea.
service. Lean tools helped eliminate non value-add activities, optimize
Roy Underhill workflow, and more flexibly respond to staffing needs. As a result,
employees are happier, overtime costs were reduced to less than 5%, cost of
service dropped 25%, and customer satisfaction increased 20%.10
9
Tefen Lean Transformation Case Study: Pharmaceutical Lab
http://www.tefen.com/objects/PDF/Case_Studies%5CLife_Sciences%5CLea
n_Transformation_Case_Study-Pharmaceutical_Lab.pdf
10
Tefen Case Study: Capacity and Resource Management for a Leading
Financial Institution;
24
Lean Thinking for Long-Term Care
Insurance
In the life, property, casualty, and auto insurance sectors, Lean is used to
analyze the impact of service complexity, capture customer needs, shape
innovation, improve response time and quality of service, and minimize
costs.11
Hospitals
According to the Lean Institute, Lean has been implemented in hospitals,
clinics, and other healthcare facilities for over 20 years. Lean Healthcare
focuses on improving the quality and responsiveness of patient care by
eliminating waste in all its forms, including eliminating errors in patient billing,
improving both the flow of information and patient flow; challenging the need
for all wait times: lab results, registration, etc12. Noteworthy Lean initiatives
and results include:
• Reduction in patient wait time for new patient exams by 26% (from an
average of 38 minutes to less than 28 minutes)
• Inventory reduction in surgical rooms of $1600 – full roll-out of system
saved facility over $200K in disposables
• Orthopedic ER wait time decreased from 200 minutes as an average to
less than 60 minutes, a decrease of 70%
http://www.tefen.com/objects/PDF/Case_Studies%5CFinancial_Services%5
CCapacity_and_Resource_Management_for_a_Leading_Financial_Institutio
n.pdf
11
http://www.georgegroup.com/insurance.php
12
http://www.theleanstore.com/healthcare.php
25
Lean Thinking for Long-Term Care
Appendix 2: Problem solving
storyboard template
Problem Solving Storyboard
Department Date
Team Name Team Members
#1 Describe the problem #2 Contain the problem
#3 Brainstorm and determine solutions
#4 Verify root cause
#5 Implement solutions #6 Verify effectiveness
26
Lean Thinking for Long-Term Care
Appendix 3: Identifying residents
who did not have a BM in last
three days
(Completed once per day for a 60 bed unit)13
13
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
27
Lean Thinking for Long-Term Care
Appendix 4: Documentation of
I&O record
(Completed once per day for 50% of residents in a 60 bed unit)14
14
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
28
Lean Thinking for Long-Term Care
Appendix 5: Skin observation
(Completed twice per week per resident in a 60 bed unit)15
15
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
29
Lean Thinking for Long-Term Care
Appendix 6: Documentation of
vital signs
(Completed once per day for 25% of residents in a 60 bed unit)16
16
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
30
Lean Thinking for Long-Term Care
Appendix 7: Unit meal intake
report
(Completed once per week for a 60 bed unit)17
17
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
31
Lean Thinking for Long-Term Care
Appendix 8: Intake and output
report
(Completed once per week for 25% of residents in a 60 bed unit)18
18
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
32
Lean Thinking for Long-Term Care
Appendix 9: Unit weight report
(Completed once per month for a 60 bed unit)19
19
Compilation of data from 3 facilities using AccuNurse® Voice-Assisted
Care
33
Lean Thinking for Long-Term Care
Appendix 10: Summary of
process flow maps
34