Getting Closer to Continuous Flow in Health Care

What is continuous flow?

In manufacturing, continuous flow occurs when a single product is built from start to finish on an assembly line that doesn’t stop. Henry Ford, inspired by the processes he saw in flour mills, canneries and industrial bakeries, began using continuous flow successfully in automobile manufacturing in 1913 to realize his goal to produce affordable cars for the population. Today, in Dearborn, Michigan, visitors to the Henry Ford museum’s Rouge factory can see how workers and machines now produce a fully functional truck down a continuously moving assembly line once every minute. At every step along the way, value — as seen from the customer’s point of view — is added to the automobile.

Toyota’s improvement of the flow model

Decades later, Toyota knew that to realize their goal of producing smaller cars that used less fuel, they would need to look deeply at the existing processes. The Toyota team observed that in the traditional Ford assembly line, the engineers set the pace determining the rhythm of assembly, and the workers on the line had no control. So when a problem occurred on the line, the workers had no way to identify the problems or stop the process — they were at the mercy of the production process that was handed down to them. The result was a system that had the potential to produce cars with defects that might be passed down to customers.

Therefore, Toyota developed a lean production system, in which they set the pace of production to the demand of the day. They respected the workers on the line — realizing that the people who did the work understood their part of the process the best. In the Toyota model, workers who saw a defect on the line became empowered to stop the process (using an andon), analyze the problem and build countermeasures back into the process to prevent the same problems from occurring again. Toyota’s process of continuous flow was inseparable from the concept of continuous learning.

At the time, the traditional mindset was “I go to work to do my work.” With Toyota, the mindset changed to reflect their new culture: “I go to work to improve my work.”

Eventually, other automobile manufacturers adopted Toyota’s refined version of continuous flow, and airplane manufacturers followed suit soon after to achieve safer, more efficient processes in airplane manufacturing.

Moving away from batching

In health care today, the norm is batching, a process that involves producing products and services in groups. This process is not only inefficient but also carries the potential of errors that can be passed down to patients. With today’s lean production system, organizations can employ one-piece flow, in which each product or service is given the attention it deserves — and fewer errors result. The best organizations are moving toward continuous flow, but we aren’t there yet.

Here’s a vision of continuous flow in surgery. A patient walks in the door and is immediately directed to a room to prepare for surgery. As soon as the patient is prepped, the operating room, surgical team and all of the supplies are ready. When the surgery is completed, the patient moves immediately to the recovery room, where the bed, equipment and nursing team are ready. As soon as the patient has sufficiently recovered, the patient moves to the ICU, where the bed, equipment and nursing team are ready.

This isn’t happening yet, but we’re moving closer.

“With today’s lean production system, organizations can employ one-piece flow, in which each product or service is given the attention it deserves — and fewer errors result.”

Improving flow in primary care

Today in primary care at Virginia Mason, patient care is continually improving. When a patient calls in with a question, the medical assistant who takes the call uses a standardized message format and frames it appropriately. He or she collects all the information necessary for the provider to make a decision and asks the patient when he or she would like a response. The assistant then sends the message to the care team with a timer. The care team — which did away with the concept of batching messages years ago — responds to the patient in the patient’s preferred mode of communication, delivering on the promise the patient got during the initial phone call.

This system is possible because the medical assistants, nurses and physicians have formed teams that have developed scripts together, created sorting tools for messages, trained and mentored staff, solved problems, refined processes and held each other accountable. Every day they meet in huddles to stay connected to the work, to each other and to their patients.

From chaos to continuous flow

At too many health care organizations, people work in chaotic conditions, physicians stay late every night and patients wait for hours or days for answers. Sometimes patients never hear back. In these organizations, workers are at the mercy of these processes, with no power to quickly help the sick patient calling. After a while, they think health care is impossible to improve. “It’s always this way,” they say. “Nothing can be done.”

But we can learn to show respect for our employees by involving them in process improvement, and moving them from chaos, to batch production and then to one-piece flow in pursuit of the perfect patient experience. And if we keep improving, our truest visionaries can lead us to continuous flow, where patients are moved along seamlessly through our health care systems and they are healthier and happier when they leave.

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