It's the Little Things

There was a lot of finger-pointing…the doctors blamed the schedulers, the schedulers blamed the doctors. The nurses didn’t know whom to blame, but knew it wasn’t them. And the hospital administration blamed everyone.

Surgery schedules were continuously slipping; getting worse as the day progressed. It’s not uncommon for medical procedures to have complications arise and go longer than expected, but schedules are built to allow for some of that. And this center had a worsening reputation for always being late. It was getting so bad that late-day surgeries were getting canceled. All the Doctors were demanding early slots. Patients were asking to go elsewhere. It was obvious that something had to be done.?

A Process Improvement facilitator with the University affiliated with the hospital was brought in to help. He was given a cross-functional team from the hospital: a good mix of people who worked all the processes. And they began.

It started with a process map; each step staring with creating the schedule, to doing the surgeries, to turning the operating suites, to transferring patients, and closing cases. The team felt they’d captured the steps, and even walked the process to confirm every one.

For the next two weeks, the facilitator used the process map and tracked the operations; gathering data and building a value stream map. Times for each step were collected and averages were created. And, looking at the results, it was clear where the issue was.

The time to turn over an operating suite increased as the day went on. After each surgery, the room had be cleaned, equipment swapped out, and surgical supplies set up for the next procedure. With the morning surgeries, the turnaround times were averaging between 10-15 minutes, with little variation. By the afternoon, the turn times were averaging over 30 minutes, with variations ranging from 15 to 45 minutes.

Everything else; the admin process, the patient prep, and the surgical times were all consistent. There was clearly something going on with the process of turning over a suite. So the facilitator went on a Gemba walk.

Donning scrubs, the facilitator lurked in the hallways of the surgical center. There were 8 surgical suites, all connected by a common center hallway. There were doors on either side: one that brought patients in from the prep area, and the other patients exited to recovery. Near these doors were nurse/admin centers and housekeeping closets. The layout was simple. No obvious physical bottlenecks.

But the facilitator noticed something as the day went on. The housekeeping staff, those responsible for cleaning the rooms were either frantically running amuck or standing around as if waiting on something.?The facilitator approached the staff and asked.

The standing around was indeed waiting. They were waiting for the mop bucket. Once they got it, they had to frantically empty it, refill it, then run it to the OR they were cleaning. The reason for this chaos?

There was only one mop bucket.

You see, in the morning all the OR Suites were clean and ready to go. As procedures began, and the teams had to turn over the rooms, it wasn’t bad as the finishing times for the procedures staggered. There was enough time to grab the mop bucket and clean. But inevitably, usually, by late morning, two procedures would finish at about the same time. That’s when the trouble began.

One housekeeper would have to wait for another to finish with the mop. This began a snowball effect of waiting. By mid to late afternoon it was always a mad scramble to get the one mop bucket to turn over a suite, and the housekeepers often had to wait, sometimes two or three rooms would be waiting on the bucket. They’d even given it a name, calling it “mop wait.”

The housekeeping staff had a request for another mop bucket for the OR center. But earlier in the year, the hospital had bought a fancy floor cleaning machine; one of those that looks like a small walk-behind Zamboni. It was great for the long hallways of the main building. But it could not be used in the OR center. Unfortunately, the machine ate up the housekeeping budget and Administration said there wasn’t $100 for another mop bucket for the OR.

Ironic Side note: This was the time coffeehouses were growing in popularity, so the admin had bought an expensive espresso machine for the OR lounge. That machine would have paid over 10 mop buckets. But it “came from a different funding source” so not money that could be used for mops. On the bright side, it gave the housekeepers something to drink while waiting.

It wasn’t until the improvement event brought this issue up to the leadership that money was to be found for another bucket. Once a second mop was available in the OR, scheduling issues greatly improved. The turnover times remained constant throughout the course of the day.

This is a lesser-realized effect of Process Improvement events. Leadership sometimes does not listen to their own people but will pay attention then they pay outsiders to tell them the same thing.

I wish I could say this was an isolated incident, but it happens all the time.

During an improvement event for a large manufacturer, we were creating a value stream map. A glaring pain point appeared: there were delays in restocking various stations with raw materials and supplies. Talking with the workers it had been this way as long as the could remember. (Average employee tenure was a little over 2 years) We estimated this issue had been around for a few years.

The company had attempted a Just-In-Time (JIT) approach a few years back. Materials and supplies were to arrive via truck as the assembly stations needed them. When done properly, this is a lean dream. Minimal inventory, minimal Work-in-Progress, and everything flows.

When not done correctly it can be a nightmare. Assembly lines stop willy-nilly as a station must wait for something.

That’s what was happening at this manufacturer.

Looking at delivery schedules, shipments were arriving as they should. But walking the process, we found the root cause.

The company had several pallet jacks on hand to unload cargo from trucks and take it to stations. Over time some of these hand jacks had broken down. It had gotten so bad they had to cannibalize parts from some of the jacks to keep one operational. They were down to one pallet jack for the entire factory.

So it was the whole OR scenario again. Workers waiting, then frantically running, while flow became a mess.

Much like the hospital, the receiving team at the factory had an order in for new pallet jacks. They were requesting motorized ones; much more expensive than the manually operated hand jacks that were there. Leadership said the motorized versions were not justified.

When the manual hand jacks started failing, new ones were requested. Leadership saw that as some sort of an end around their denial for a motorized jack. So they denied the new manual ones as well.

The team then requested repair services for the broken jacks. Evidently, that fell under plant maintenance and a different pot of money. Since repairs on broken jacks were not something done before, there was no budget for them. It was awaiting the budget requests to be made in the upcoming fiscal year when the improvement event happened.

Another Ironic Side Note: Despite no new jacks, the company had set up new Keurig-type coffee machines throughout the factory. One of which could have paid for a new jack. But the dock workers had great coffee to enjoy while waiting.

When we reported the root cause of the lack of pallet jacks disrupting the entire factory’s flow, money was found to repair them.

Small things impact larger outcomes. This has been observed for centuries. In the 1200’s the famous proverb was created:

For want of a nail, the shoe was lost,

for want of a shoe, the horse was lost,

for want of a horse, the knight was lost,

for want of a knight, the battle was lost,

for want of a battle, the kingdom was lost.

So a kingdom was lost—all for want of a nail.

Over 800 years later, and we are still re-learning this lesson…