TMC wraps up summer challenge asking employees for their best ideas

Tucson Medical Center five years ago embraced the Lean management process, which works to eliminate waste and tap the knowledge of employees to make steady improvement every day.

The Summer of Ideas challenged employees to channel their creativity and share their suggestions across the hospital.

More than 250 ideas were submitted since the July kickoff. Awards were given for the team and the individual with the most ideas, as well as the best “out of the park” idea.

Some of the ideas included a TMC-specific rideshare program, new software for clinicians and an app to help patients and visitors navigate the campus.

LeanAmyThree of the four finalists – and the winner of the category – for the most ambitious idea generators work in Unit 750, an adult medical unit. Unit clerk Amy Hill, who came to TMC six years ago, won a reserved parking space for a month.

“What I really appreciate about TMC is that there is an acknowledgment that those who are closest to the work often have the best solutions to improve a process,” Hill said. “I appreciate that whether it’s finding root causes of a problem or finding the where efficiencies are, we can all have some ownership of making things better.”

Janet Heckman, the manager of Unit 750, applauded the efforts of her staff. “Taking ideas from the front line staff who actually do the work is very important as I may not realize there is an issue,” Heckman said. “I also believe being heard is a huge employee satisfaction point as they feel empowered and heard.”

Ideas were logged on a Lean tool known as an “idea board.” There are 120 idea boards throughout TMC as well as at TMCOne locations and TMC Hospice.

It’s different from a suggestion box in that ideas – as well as any outcomes or solutions – are visible to the entire team, who can contribute to the idea as it matures, said Pat Ledin, the manager of Lean and quality efforts at TMC. “We hoped the Summer of Ideas would serve as a fun catalyst to continue driving engagement and we were really pleased with the participation across so many of our departments, from environmental services to information technology to clinical staff.”

lean ideas

Medical librarian Marni Dittmar, who picked up an extra day off as an award for her most “out of the park” idea, is an example of how the process worked. She not only came up with her idea for new clinical software, but then researched it to determine the benefits and feasibility.

Click here to see a short video about how idea boards are igniting creativity and empowering staff at TMC.

“She gained as much as she gave.” TMC Volunteer contributes to major improvements for diabetics’ care

Marjorie Zismann TMC Volunteer

Marjorie Zismann
TMC Volunteer

“You have diabetes.  Buy a book.”

That’s what Marjorie Zismann’s doctor told her when he diagnosed her with type 2 diabetes in her early 60’s.  Since then, attempts to understand her disease have left her completely frustrated. Every day, she weighs herself, pricks her finger, squeezes out a drop of blood to check her blood sugar and takes her medication. Mealtimes consist of sorting out “yes” foods from “no” foods, which leaves her feeling restricted with little control over her disease.

Now 78 years old and retired, Zismann volunteers at Tucson Medical Center. She was a patient here about a year ago, and was invited to be a patient advocate during what’s called a “kaizen.”  It’s a rapid-improvement workshop made up of about a dozen leaders from different departments who set out to tackle a very specific issue. The meeting is a crucial process of TMC’s journey to a Lean culture, which produces patient-focused, reliable, safe and compassionate care through continuous improvement and the purposeful use of our resources.

The challenge of this particular kaizen: improving glycemic management for TMC patients with type 1 diabetes and keeping them from having multiple hypoglycemic, or low blood sugar, events during their stay. For three days, members from pharmacy, dietary, and the diabetes educators, among others, dug into how to provide better care for these patients. “Every time an idea was pitched, we’d run it by Marjorie to get the patient perspective,” said Pat Ledin, a member of the TMC Lean Team, which organized the kaizen. “We’d ask her, ‘Would that help you? Would that offend you?  How would that make you feel?’ We can’t stress how important it is for us to hear the voice of our patients and involve them in every change and process improvement.”

The visual cue that was created to alert staff to patients at risk for hypoglycemic episodes

The visual cue that was created to alert staff to patients at risk for hypoglycemic episodes

Some improvements were made immediately, including educating the medical staff who are on the front lines. Special signs were created and placed on the doors of patients with diabetes to serve as a reminder to staff that a patient is at risk for hypoglycemia.  Finger sticks are done on a more consistent basis, which allows for more coordination with meal times. Pre-packaged “snack attacks” are readily available for when patients do have an episode. “These have the right number of carbohydrates and protein, so it’s the perfect snack for this type of patient. It’s bulletproof,” said Ledin. Supply kits have been streamlined, there is a standardized approach to what staff does with a patient’s medication, and there is more consistency in how these patients are cared for among different departments.

One thing the team found may be contributing to more hypoglycemic events – TMC’s On Demand Room Service, which allows patients the flexibility to call in their meals whenever they’d like. It’s without a doubt improved overall patient satisfaction scores, but for those with hypoglycemia, it can add confusion about appropriately coordinating meal times. TMC Lean Team leader Cheryl Young explains, “On Demand doesn’t work for these people because their insulin is associated with their mealtime. If they eat at 9 a.m. for example, and want to eat again at 11 a.m., our On Demand service allows them to do that. But if they do, it could cause a hypoglycemic event because the meals are too close together. It’s best to have at least four hours in between meals. So we’re educating these patients that although we have this service, it’s not necessarily the best thing for them and their disease.”  Another little nugget of information that Zismann has found invaluable at home.

“As a result of this kaizen, we now have a standardized approach for the food, medication, education and visuals for these patients,” said Young.

Just one month later – dramatic results.  “With these patients, their disease process causes the hypoglycemic event to happen. But now we are seeing the repetitious events minimized during their stay here, which is a direct result of the improvements put into place from the kaizen,” said Ledin.

Zismann said she learned more about her disease during those three days than she had since her diagnosis more than a decade ago. She discovered TMC has diabetes educators who are available to help patients. “For me, the most frustrating thing has been to try and figure out what I’m supposed to be doing,” said Zismann. “TMC Diabetes Educator Nancy Klug was tremendous. She opened my eyes to the fact that I CAN eat certain foods, I just can’t eat much of them. I left her office feeling so empowered, and relieved that I really didn’t need to be so restrictive!”

Zismann admits she still has a long way to go before fully understanding her disease, but calls the opportunity to join that kaizen “one of the best things that’s ever happened to her.” “I felt like part of the group,” she said. “These people care. They come up with wonderful ideas. They work well together. It was unbelievable to watch them, and I have learned so much from the experience.”

While Zismann is applauding their efforts, the kaizen team leaders insist they’re the ones who were fortunate to have her there.  “We were able to collectively come to better decisions that have already led to better outcomes for our patients because of what Marjorie brought to this process as both a patient and a volunteer,” said Young.  “I think she absolutely gained as much as she gave.”

If you are interested in acting as a patient adviser for a particular department or issue, please contact Angie Bush at (520) 324-5512 or Angie.Bush@tmcaz.com.

To contact a TMC Diabetes Educator, please call (520) 324-3526.

Emergency Department reduces wait times; sees increase in patient volumes

LeanEmergencyEmergency Department director Melissa Ritchey and the staff were feeling discouraged in January 2013. Wait times in the department were too high. Too many patients – as many as 7 percent in some months during 2012 – were leaving without being seen.

When she learned Tucson Medical Center would embrace a “Lean” management philosophy, she was first in line. “I needed help. We had tried a series of strategies, but it just seemed nothing was working.”

The staff got to work, relying on multidisciplinary teams to break apart and deeply analyze steps in a process, looking for inefficiencies and bottlenecks.

Example: In 2013, it was taking as much as 30 minutes from a time a patient received discharge instructions to the time that patient was walking out the door. Staff set a goal of 15 minutes to more quickly free up beds for other patients.

Every day, staff huddles to track the numbers, troubleshooting problems they encountered when they miss any target such as the 15 minute mark. Sometimes, they’re so eager to see their measurements that they call and ask for their numbers if they are not working that day.

That kind of engagement is reflected in measurements.

Wait times in the main emergency room have dropped from an average of 4.6 hours to meet the industry standard of 3.5 hours.

By 2013, staff had reduced the number of patients who left without being seen from a high of 7 percent the year before, to 3.5 percent. This year to date, that number is 1.75 percent.

“It has been a culture change, the department is not what it was like 5 years ago” Ritchey said.

She admits when she first heard about Lean, she was a bit skeptical, since other strategies had not made a dent. The difference? “This process really does empower the staff. It’s really about generating a sense of ownership.”

Emergency room nurse Heather Williams agreed. “This is a very different place now than it was a few years ago. Staff is really involved in helping to determine what works and as a result, we’re really working as a team and there’s much more pride and ownership than ever before.”

For Ritchey, was it difficult, as a manager, to let go? “You always hear that it’s hard to look at the big picture when you’re always trying to put out fires. Now, if a computer is broken or we need to come up with a holiday schedule, the staff takes ownership, and it really has allowed me to focus on the big picture and assure the staff have what they need to care for our patients.”

“For a manager, it’s really about finding that balance between when you need to issue clear directives and when you can step back and let staff decide how to take care of it.”

She thinks happier patients and happier staff worked together to fuel another happier number: Higher volumes. In May 2014, the department saw 500 more patients than the previous May, with year-to-date volumes 7.5 percent higher than expectation.

On-demand room service improves patient experience

Food Services lean blogNo matter how great the care, it’s hard for a hospital to replicate the freedom and comfort of home.

But even if patients aren’t able to get up and make a grilled cheese sandwich, Food & Nutrition Services determined that giving patients more control and power over food choices certainly goes a long way to increasing the feeling of freedom during their hospital stay.

To impact the patient experience, the department utilized Lean tools to help transition from predetermined meal times to an on-demand room service model that allows patients to order meals at their convenience from 6:30 a.m. until 7:30 p.m.

The staff worked hard to gear up for the May launch of the program.

One of the first Lean steps was to “5S” the area. This workplace organization tool stands for sort, straighten, shine, standardize and sustain. Any broken, unused equipment was repaired, replaced or removed. Everything got a deep cleaning. Tools and drawers were labeled and standardized.

Daily huddles were implemented to share pertinent information with all employees and allow for problem solving. Idea boards were installed to allow employees to recommend solutions, since they know the job better than anyone else.

While planning the transition, the team mapped each step that happens from the time a meal is called in until it is delivered. After analyzing the flow to look for inefficiencies, staff performed a series of simulations, using poker chips as food, to try to identify where the problems may occur prior to going live with the changes.

Work continued after the launch.

Staff continued to seek out root causes of any setbacks and develop solutions. The idea board was a popular tool. For example: runners taking trays to patients now double-check the order against the tray before ever leaving the kitchen, ensuring accuracy and providing an opportunity to make immediate corrections.

Quality metrics are tracked at every meal and discussed in the daily huddles. One of the quality measures tracked is the delivery time of food, which is 45 minutes from the time the food is ordered. When targets aren’t met, the team discusses the issues at the huddles, pinpoints why they’re happening and takes action.

Beth Dorsey, the director of Food & Nutrition Services, said data is already showing progress. Food waste has been cut in half and patient satisfaction scores are improving. Patients who checked the top box of being “very satisfied” with their meals jumped from about 30 percent to more than 40 percent in May when the program was first unveiled. With the “go live” issues ironed out, she anticipates patient satisfaction will rise even more.

Throughout the entire Lean transformation, there’s been another marked improvement, she said. “It’s really been an amazing culture change here because the staff has really embraced the tools that Lean provided to us to improve our ability to care for patients.”

Staff is empowered to share their ideas and be engaged in the solution, she said, and with greater accountability comes greater opportunities for coaching. Managers went from a “tell-me-the-problem-and-I-can-fix-it” mentality to a “tell-me-the-problem-and-I-will-support-you-to-make-sure-this-is-fixed” approach.

“Ultimately, we’re in the business of nourishing our patients and fresh, quality food is at the heart of that goal,” Dorsey said. “Lean has given us a framework to work as a team to do our part in improving the patient experience.”


Tucson Medical Center | 5301 E. Grant Road | Tucson, Arizona 85712 | (520) 327-5461