How to Succeed in Your Joint Commission Survey with Lean

A medium-sized hospital on the East Coast passed the Joint Commission’s audit in December 2010 with flying colors. The lead surveyor had this to say in the exit interview: “Very few finds from an organization of its size are truly remarkable and incredible.” First consider the typical amount of work and stress during the weeks and months leading up to a visit by the Joint Commission inspectors. Now think about a future where you really look forward to the visit and your chance to show off to the survey team. This is a very achievable goal. Take care of your processes and the Joint Commission survey will take care of itself.

The best way to develop and maintain a process approach and a process improvement approach in your hospital is to adopt the Lean philosophy and principles. The Joint Commission itself has adopted Lean as its own process improvement methodology. For example, see the article “Don’t Just Talk the Talk: The Joint Commission Approaches Its Own Processes with Lean and Six Sigma, Quality Progress, July 2009” on the Joint Commission website.

The following are the five critical areas identified by the Joint Commission’s comments in its survey, along with some recommendations from the lead Lean consultant assigned to this hospital.

Recommendation 1: Launch a strong visual workplace and 7S program

7S is a formal approach to organization and maintenance, and is the cornerstone of the Lean approach. Pollsters talked a lot about the hospital’s 7S program. They openly commented that this was one of the best organized work environments they had seen in a long time. To achieve this requires discipline and vision from the leadership ranks. At this particular hospital, the CEO did a departmental 7S project, along with a well-organized office, as part of the annual review for all hospital leadership.

It should also focus on something other than the traditional 5S program that most books write about. This hospital embraced 7S, to include Safety and Security for each project.

Here’s how to get a great score on your survey in this category.. Train at least one or two 7S Mentors per department and unit. These people are not supposed to do all the work, but are to be available to staff members when 7S projects start.

Divide the hospital floor plan into a grid and assign an area to each executive to round off the 7S state. Make sure each executive is aware of the projects that have been completed, so they can stick their heads into the areas and give them a cursory review. Note to executives: If you walk past a messy area and say nothing, you are tolerating the behavior. If you really want to make a difference, put on a robe, roll up your sleeves, and help fix the problem. You now have the moral authority to point out the mess and demand its rectification.

Recommendation 2: Implement strict supply management with Kanban

The Perioperative Services Administrator had the opportunity to shine by explaining the new and much more efficient supply replenishment technique adopted by the hospital, the Kanban system. This hospital adopted Kanban as a methodology to replace the PAR system. The PAR level system is a failed methodology that you should abandon as soon as you finish reading this article. Surveyors were also impressed by the organization of supplies, driven by Kanban management.

Here’s how to get a great score on your survey in this category. This one is simple, just implement the Kanban replenishment system for all your supply points. This is one of those issues that you will have to combat with your Materials Management department. Demand that your unit’s supplies be replenished using Kanban. You may think that as long as the supplies are there, you shouldn’t care how they get there. Stop and ask the staff how often they have to call materials management, clamoring for supplies that should be there. Next, ask yourself how rational it is to count each supply every dayWhich of course no one does.

If you can’t get your materials management team into the 20th century, do a small pilot project with supplies that are not under your control. Then show the results and try again until he sees the light.

Recommendation 3: Achieve a high level of staff engagement

One of the apparently “misleading” questions to the Director of Process Excellence was “and who does the actual project and the implementation of all these Kaizens documented by your department?” His eyes lit up when the reply “well, staff, of course. Registered nurses, technicians and all appropriate stakeholders” came.

Successful Lean companies are not about “the select few” but about a culture of continuous improvement that engages everyone. An engaged workforce is the trademark of a mature Lean company that will see the long-term sustainability of its efforts.

Here’s how to get a great score on your survey in this category.. Train everyone and slowly remind each staff member of the importance of continuous improvement. Some hospitals hear about Lean and want to rush out and hire some engineers to create their own “Process Excellence” department. We recommend that you DO NOT do this. Don’t even think about starting a “Lean Empire”.

Create a department to manage and coordinate the training and projects of each department and unit. This department should not do the projects, since they must be carried out by the officers of the units that identified the opportunity for improvement.

Recommendation 4: Understand and implement a Lean Management System

The Joint Commission surveyors were very interested in tracking the results of Lean projects with the same metrics the hospital uses to track its performance, rather than creating new ones. It is very important that the fruits of your Lean labor are reflected in metrics such as patient discharge performance, patient satisfaction, physician satisfaction, and staff satisfaction. This doesn’t mean you shouldn’t track other metrics such as patient room turnover, shortage per day, and OR Suite turnover, but these should lead to better overall hospital performance.

Here’s how to get a great score on your survey in this category.. If you haven’t already, link your Lean efforts to metrics on existing dashboards. Every hospital we know of has a management board. We recommend that you do not create a new one. Keep the board updated and have a methodology to deal with deviations.

Deploy local dashboards and use your physical location to host a daily 15-minute accountability meeting with department management. These local dashboards may or may not have the same metrics as the built-in admin dashboard.

Implement the leading standard work. The closer you are to delivering value, the more standardized your work will be. If you’re a member of the management team, it doesn’t mean you don’t have a standard job. An example is an end of day checklist for the SPD Manager to check the status of the department each day before going home.

Recommendation 5: Insist on management commitment

How do you expect a member of hospital leadership to understand and commit to your hospital’s Lean initiative if they don’t understand the principles and tools? They will not. The best case scenario is that some will do their own research by reading some books (or maybe Wikipedia), while the most likely scenario is that most will pay lip service and resist any requests for resources to complete projects and maintain improvements in the processes.

Here’s how to get a great score on your survey in this category.. All members of the leadership team are required to attend a training session where they have the opportunity to learn the principles and tools and practice them in their own live projects.

Structure this training session as follows:

Day 1 AM: Conference: Basic concepts of Lean and Kaizen. Form teams and identify 5 opportunities per team. One of them will be the PM project.

Day 1 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 2 AM: All teams report on the previous day’s projects. Reading: Kanban and 7S. Select the PM project in Kanban and/or 7S.

Day 2 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 3 AM: All teams report on the previous day’s projects. Reading: Standard Work. Select the PM project under Standard Work.

Day 3 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 4 AM: All teams report on the previous day’s projects. Reading: Value Stream Mapping (VSM). The class stays together and selects an area to map.

Day 4 PM: The class completes a VSM of the selected area.

Day 5 AM – Finish VSM planning by adding all opportunities identified during the mapping exercise into a continuous improvement database. Close the morning by developing a plan for the value stream using simple goal implementation tools (Hoshin Kanri) such as the A3-T team charter and the A3-X chart.

5:00 p.m.: Presentation of the group and celebration.

The above comments, stories, and suggestions are not intended to be a complete set of solutions. It is mainly some lessons learned during a very successful Joint Commission Survey and the work in the months leading up to that survey. As you consider adapting Lean as your process improvement methodology, there are many other tools that are just as important as the ones mentioned here. These other tools were also adopted by this hospital.

Now, it’s your turn to take action. The Joint Commission survey does not have to be a stressful event. Surveyors look for robust processes. Focus on your processes with a Lean perspective, and you can even look forward to your next survey.

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