Healing Healthcare, Cindy Jimmerson Interview

     Cindy Jimmerson (cindyjimmerson@leanhealthcarewest.com), lean healthcare pioneer and former nurse - she's got street cred -  lives in a canyon along the Big Blackfoot River, the setting for the film A River Runs Through It, ten minutes outside Missoula, Montana, but she got her start in Lean doing research for the National Science Foundation “Innovation in Industry.” 

biggest industry in the country and the most messed up,” she recalls. She was intrigued by the idea in 1999 of applying new methods to healthcare and the NSF funding provided her opportunity to try out Toyota methods initially in a community hospital, and ultimately in a large multi-facility healthcare system.  One of the results of that work was an interactive course and workbook first published in 2003 entitled reVIEW, realizing exceptional VALUE IN EVERYDAY WORK that helps the reader view work differently by applying principles and methods from the Toyota Production System. This publication remains the foundation workbook for all courses that she teaches, a major tool for observation that has held up well, now in an expanded second edition.

“We also wrote a really handy guide and copyrighted two programs, one a Green Belt for Healthcare Certification, and the other a similar Green Belt Certification Course for Facility Design.  Both use the same Lean concepts, but the facility design courses that we teach are specifically focused on preparing for facility design,” says Jimmerson, “so an owner, an architect or a hospital – and this is where they have the OMG! realization, can design a hospital that works better.”

Certified sitting?

The world is filled with certification courses and excellence awards – you’ve got your Baldrige, your Shingo, the Shewhart Award, the Deming Prize, the Best Plants and the Manufacturing 100 and until Purchasing Magazine folded last April we had the Purchasing Medal of Excellence.  Not to forget the Shipman Award, APICS Romey Everdell Award, the AME Manufacturing Excellence Award, and the Oscars.  But what does it all really mean?

Jimmerson feels that although the book she put together was one that anyone could use for Green Belt certification “it’s not just in class where you learn the concept.  I believe to earn the certificate you have to show competency – the course is four full days long, so of course there is a lot of talk and practice.  But then the students have ninety days thereafter to do a project.  It starts when they bring a project idea to class, and we talk about how to choose and scope a project.  Next they select the work, and we go over it again in discussions.  The point is,” she emphasizes, “you can’t get certified by sitting in a chair. I have to say that for years I was really resistant to the certification thing – I don’t like certification for sitting and listening.  I like people to go out and prove they can do the work.”

Optimizing with 3P Thoughtful Design

    There’s a process called 3P for Production Process Preparation that I saw on a trip to Pella, the Iowa window-maker and Maytag to

observe production cells and other innovations.  I loved it, and felt that it was an important breakthrough process that allowed engineers and production people to experiment and see changes laid out in cardboard and plywood before they moved a machine or a work cell.  It seemed to me that although kanban and supermarkets were kind of exciting to many work teams, there was no mystery, there were no surprises inherent in these very simple methods.  But 3P was visually powerful, the kind of tool that could be used to bring other people, machine operators for instance, and warehouse people into the process as well.   So when Jimmerson said her team was doing work in hospitals using 3P methods, I felt the shock and relief that most taxpayers should feel when they meet someone who can actually lower healthcare costs.  “Although we started working with Lean in the nineties it didn’t take two minutes to figure out we could improve healthcare with Lean thinking.  Then we realized we could redesign a hospital if we used Lean, could cross train staff, we could rotate them if we knew where to place materials.  We started banging on this eleven years ago and first presented this to a group of architects in Berkeley,” recalls Jimmerson. Sutter Health has led the way in Lean facility design with its roots in that same group of innovative and curious architects.It’s a different way of approaching healthcare, not the assembly-line methods prevalent through the fifties, but a way to better utilize flexible workers and well-designed work flows.  “So what has happened has really caught on,” she said, almost surprised by the momentum.  “Architects added 3P to the pre-design phase. I have forever said that this problem is not fault of the architects - they ask ‘what do you want?’ We in healthcare haven’t given healthcare workers the right tools to look at their work and answer that question with any science .  It gets pretty shocking.  I stood at very well known hospital, for example, when the design guys came into the lab and said, ‘Well, what do you want? – how about a window over the sink?’  And then they walked out, because the staff didn’t know where to start answering the question.”Nothing new there! I thought.  “But,” she continued, “it had nothing to do with the flow of the work.  Because it’s not the architect’s job to understand what the lab people do!  It’s easy to assume that people are experts and that they know the answer.  But in this revolution in health care we have equipped any worker - lab worker, housekeeping, pharmacy, etc. - with value stream mapping, A3 problem solving, etc. - anybody without a lot of engineering background can do this!”

So now what Jimmerson’s team does is work with hospitals in the pre-design phase of a new facility before the architects start to draw.  They’ll work with the staff, the Emergency Room, for example, and ask them what processes are most broken, figure what can be done to improve, before the staff moves into the new facility. Representatives of the design team participate to get first hand information about what changes the staff think will really add value to the patient experience.

Commonsensical but takes some time

It’s a simple and exciting process.  First, the team draws out the current state value stream map, locates all the activities that happen now and identifies all the points that are broken, redundant, missing, etc.  Next, they produce a future stream map that shows how they would like the process to be more effective, less frustrating.  They pass the future state information to the design team.  So the architects are working not with just bigger or prettier versions of the same old design thing.

It’s clear that Jimmerson loves this work.  “Now,” she adds, “the architects come in with us on the future state to understand how to do it differently.”

Production process preparation

3P involves actual testing using mock-ups of machines, work cells or work flows.  (see The Perfect Engine, Sharma and Moody, Chapter 7 “Design for Lean Sigma,”  Free Press, 2001, p.173-199).  Armed with a floor plan, the team can then lay the future state map on the floor plan to test how the future state works.“Really, for years, we got these distress calls.  ‘Help! – we just built a new hospital and it doesn’t work - can you come help us!  It’s refreshing that many healthcare facilities now call in advance – ‘We’re thinking about building or remodeling, please come and help us get started.’  These are projects we love to facilitate.”  What’s the bottom line?  Hospitals are being built with less square footage, more flexibility and they can eliminate a lot of activities - walking, picking and placing, retracing steps -  that they don’t need to do. Moreover, when workflows are redesigned with more flexibility, it is possible to reduce staff hours – money!Here’s a great example.  Jimmerson’s group worked with a small hospital in Oregon in the pre-design phase of a replacement facility.  The old building footprint was familiar – many floors, separate departments – obstetrics in the east wing, medical surgery in the west wing, pharmacy in the basement, etc.  But one of the team’s future state criteria was to flex staff across departments. What would happen if the emergency room were put next to medical surgery, might the staff be able to flex across boundaries?  Brilliant!  If the staff could see across to a mix of patients, it just might work!  Jimmerson realized, “If you have one person having a baby, you don’t need three nurses there.  We could have the same nurse keeping an eye on the labor patient and medical surgery.  It’s a good workload for the nurse and it’s very good for smaller hospitals.  But to do that the team had to map out how the staff had to travel to get supplies, just like in manufacturing.  We discovered the hospital needed point-of-use pharmacies.”

Along the way Jimmerson’s team has made inroads into complexity reduction.  In hip replacement surgery, for instance, they were able to reduce redundancy when they realized the hospital was stocking ten different brands of hip replacements to satisfy fifteen surgeons’ various requests, all in a full range of sizes, plus left and right sides.  The doctors narrowed down to four brands, which resulted in enormous cost and space savings. “The inventory was outrageous, with huge amounts of space and money dedicated to this proliferation of parts. It’s about recapturing and protecting real estate – we didn’t want to lay out a facility to store stuff we don’t use everyday in this premium real estate.”

Explains a lot about why healthcare costs so much!

“The cool thing,” notes Jimmerson, “is we don’t tell the team how to do it, we facilitate Lean thinking and methods to get staff to define where time is being wasted, what’s not on hand, what things are causing risk and safety issues, and where the cost is going up with no value in return.”

Elsa Mersereau (elsa@leanhealthcarewest.com) works for Jimmerson’s Lean Healthcare West and as a young engineer who has chosen healthcare as her professional home, is excited about the work with facility design.  She has co-authored a whitepaper on Lean Facility Design with Jimmerson, based on recent experience.  “The lessons we learn with every engagement are unique.  So many amazing improvements are identified by the people who do the work when we get into really understanding the challenges of how the work happens now.  It’s such great information for launching a future state that will work better for the patients and the staff.”  (For free download of this whitepaper go to www.leanhealthcarewest.com)

Jimmerson has extended this approach to over one hundred fifteen health care organizations.  “We don’t go in and create extended consulting engagements– that’s not the intent,” she warns.  “After three to four months we can leave and they use our course and our material to extend Lean through their own organization.  We’ve worked in so many environments with amazingly similar results, from single physician provider practices to Mt. Sinai in New York City where we helped them  prepare to introduce an IT management system to 56 nursing units.  The applications are endless.”

                                                                                                                                          The Big Blackfoot River outside Missoula, Montana.  Photo by Cindy Jimmerson

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