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How a NYC Hospital Adopted Toyota's Legendary Change Methods to Dramatic Effect

I recently had the pleasure of meeting Todd Hixson, who directs the performance improvement program at Metropolitan Hospital, a 341-bed unit of New York City’s mammoth Health and Hospitals Corporation (HHC), which, serving 1.3 million people annually, is by far the nation’s largest municipal health care system. Todd’s program, aptly named “Breakthrough,” has produced stellar results in an environment that, let’s just say, doesn’t always roll out the red carpet for new ideas. But it’s hard to argue with numbers like 17 percent outpatient revenue growth on a mere three percent increase in patient count — numbers directly attributed to Breakthrough.

As our conversation progressed, I was struck by the apparent similarities of Todd’s challenges to those of case managers: operating effectively in the big, grey zone between administration and medical practice; fulfilling a mandate of efficiency; and amidst all that push and pull, keeping patient needs paramount. Understanding how Todd goes about his work, I believe, can help benefit yours, both short- and long-term. Todd’s job is finding ways to improve his hospital’s operating and administrative procedures — in essence, looking at everything that surrounds the actual medical work, and that at times directly touches it. In play are patient records, managed care administration, billing processes, intake and discharge, how patients physically move around the hospital, and more.

“From a broad perspective, my job is improvement by increasing efficiency, balancing what I call ‘customer value added’ and ‘business value added’ at every step,” Todd explains. “That said, when it’s a jump ball, the patient always wins. They are, and have to be, the primary customers.”

Todd gives HHC’s management the credit for instituting a distinctly un-bureaucratic approach to process improvement — one, known as “Lean Thinking,” he deeply believes in. Closely associated with Toyota, and oft-cited in the automaker’s global success, lean here means “delivering service to the customer on demand without defects.” Over the past 18 months HHC, working with Lean consultants Simpler Healthcare, has deployed Lean improvement methods to most of its larger hospitals.

Lean's central idea is identifying and reducing, if not wholly eliminating, wasteful practices, for an organization’s ongoing — in theory, never-ending — improvement. Lean’s method and difference is empowering those in the trenches to find solutions themselves. In an industrial company like Toyota, that means factory workers contribute not just muscle power, but brainpower, too.

Whether at an auto plant or inside a health care facility, the Lean Model calls for pulling teams together — mostly ad hoc, sometimes from a variety of functions — for what’s known as a Kaizen (Japanese for “continuous improvement”) Event. Each event is built for rapid change, implementation and tangible outcomes, and centers on:

• Defining a problem;
• Getting data about that problem;
• Building a team to solve it;
• Charging the team with generating ideas, and identifying the best idea; and
• Implementing that idea in a practical way — one where it can stick — and dispassionately judging results.

“One of the things we instill early on in our teams is not getting too hung up on the data,” Todd says. “The numbers and background of course are critical, but they can also be a barrier to creative thought and achieving anything really tangible. We want new and good ideas, fast, that can be put into practice, fast.

“Let’s get it out of the conference room and into the clinic, we like to say. What works, leave it there, and what doesn’t, let it go,” he says.

Todd offered a prime example of Lean in action in the improvements made in his hospital’s surgery clinic, illustrating how pulling from a sequence instead of a batch (classic Toyota methodology) increases flow throughout an entire process.

Metropolitan’s surgery clinic followed fairly standard protocols, scheduling multiple patients at the same time with one doctor. That’s a classic “batch and queue” model allowing a doctor to “work the pile” (of charts, not people)," in part assuming patients don’t all arrive on time. You know far better than I what tends to happen under this scenario.

“While perhaps not a big leap for other sectors, our group’s idea to sequence appointments in 15- to 20-minute increments, and to tightly enforce each slot as ‘use it or lose it’ were huge changes for our facility and the community we serve,” Todd recalls. As a result, the clinic has reduced the average time for an encounter from more than 90 minutes to less than 60 minutes and increased patient volume 10 percent.

Another team working in the emergency department's "fast track" urgent care service dug into every aspect of the intake and examination process to deal with the high walk-in volume typical of a New York City emergency room, taking the patient's point of view at every step. The result was unusual for a clinical setting, but has proved remarkably effective and durable. Instead of moving patients all around the facility — to one place for paperwork, another for vitals, back to the waiting room until an examination room becomes available — patients are given a room from the start, and remain there throughout their visit. Staff comes to them for every step. The hospital's fast track service now sees twice the number of patients than it did previously, relieving its overburdened emergency room.

“On paper, the group’s idea was labeled O.M.P.O for ‘only move patient once,’ and its beauty is in its simplicity,” Todd says. “It requires doctors to do not only patient consulting but also discharge, eliminating time-consuming hand-offs back to nurses and others. As you’d imagine, that change didn’t come easy, but now, the clinic would never go back to the old way.”

The Lean mindset requires standardization of some work processes that practitioners may proudly view more as art than science — processes that were previously assumed to be either immune to, or wrong for, consistent and prescribed implementation. "If I'm doing my job right, I'm communicating precisely the opposite — which couldn’t be more true — that the more we can standardize, the more time you’ll have to do what really matters,” Todd says.

The critical step often occurs before, not after, an event. “We’ve learned to ask more and better questions, investing those who will be affected at the outset in helping us identify processes that might be helpful,” he says.

I asked Todd how case managers could best implement Lean principles, if not full-on processes. Some of the key things he recommends include:

(1) Think Lean. Be a change agent. Look at everything that you do (or that affects your work) through the prism of — “Can it be done more efficiently, with a better return on time investment?” This has roots in a big idea we explored in the June issue, Spangler’s Law of Manifestation, which holds that our thinking drives our actions, and, ultimately, the results we generate. You can easily see how Lean thinking can impact this chain.

(2) Choose big, winnable battles. When advocating for change, go for a big win, where positive results, if achieved, simply can’t go unnoticed. “Most of the time, we wind up spending the same amount of time fighting small fights as we do prize fights. So go for it,” Todd advocates. But even as you think big, do choose battles you feel can realistically be won.

(3) Remember to take care of yourself. None of this is to suggest implementing change is easy. It takes hard work and perseverance, and generates stress in even the most resilient types. Recognize these facts and be kind to yourself. Give yourself an occasional time out from change advocacy when you need it. Enlist like-minded others to join the battle to relieve some of the burden and gain additional firepower.

 

Dr. Vergil Metts is president and CEO of Impact Associates Inc. and holds a doctorate degree in industrial and organizational psychology from the University of Tennessee. Dr. Metts has extensive experience working for and consulting with public and private organizations. Dr. Metts can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .