The Battle for the hearts and minds
As a professional implementer of Lean principles in hospitals for the last decade, I continued to be amazed by the fact that hospitals are painfully slow at putting in place simple and effective materials replenishment techniques. The great majority of all hospitals cling stubbornly to the bankrupt “par level” method to handle their supplies. When we explain to clinicians other ways to deliver supplies that would eliminate wasteful supplies-related activities, they normally jump on board. It is not the clinicians that oppose bringing 20th century tools (yes, I said 20th century on purpose) but the materials management departments, entrenched in their old ways.
It is not all doom-and-gloom, though. There are some visionary Materials Managers who, once they go through a simple simulation or a “Par vs. Kanban” game, see the light and realize that “par” is a waste of time, effort, and money. What do you do then to move forward? How do you go about implementing Kanban in a “par” environment?
The first thing you need is an implementation roadmap along with the decision about where to introduce Kanban first, so you get bang for your implementation buck as well as a high psychological impact on staff. Your roadmap should follow the steps detailed below:
1. Document you current supplies strategy. Do a formal analysis of the current supplies management methods, metrics and benchmarks. You will use this data later to compare against the new system. Make sure that you capture inventory dollars and inventory turnover.
2. Select the target area. We recommend that you start where you will get the most out of a small implementation. Do not become Don Quixote and go after the entire hospital’s supplies in one project. Here is my recommendation: start with the cabinets in the OR suites. This will account for less than 100 items, and it will make the OR staff eternally grateful for easing this pain.
3. Identify the supplies. Develop an exhaustive list of all the supplies in the cabinets and drawers. Getting staff input on this step is a key to your success and sustained results.
4. Gather calculation data. For each supply, it will be necessary to obtain part numbers, descriptions, alternate descriptions, usage, and location information.
5. Set up the Kanban database. It is preferred that you use your existing materials system for this step. If this is not possible, you will need to have a central repository of data for the Kanban information. An Excel spreadsheet is your best bet.
6. Perform initial calculations. The calculations are very simple. Establish how many days of inventory you want to support this OR, and establish that quantity for each item. From the initial Kanban Sizing, determine which items will require the Multi-Card, Single-Card, or Sequenced Delivery method. Code these items in the Kanban Database file.
7. Develop a plan for every part. A complete planning profile will need to be added for each item, including container sizes, supply chain strategy, label size and type, and supplies handling plan.
8. Perform a Joint Commission and Infection Control check. Prior to making any physical changes, engage the Infection Control Team to ensure that all the proposed changes are aligned with regulations, internal policies and procedures, and best practices.
9. Assess the systems impact. Ensure that the largely manual Kanban method will be integrated with bar-coding, RFID readers, and electronic inventory systems for inventory accuracy, traceability, purchasing and patient billing transactions.
10. Deploy the Kanban system. Don’t underestimate the amount of work required to physically put in place the containers and racking for the line, supermarket and stockroom areas. Time yourself and see how long it takes to set up a complete Kanban bin, say 3 minutes. Think of the 100 items we talked about before, and now multiply that by 2 bins and 3 minutes. That is 600 minutes per OR suite! To be fair, it will get easier as you get more practice. It is also very important to identify all the roles in the new system and assign those roles to individuals or functions. The big question is who is going to replenish the OR Suites and the Supermarket in the Sterile Core? In one of our Kanban projects, the SPD Manager actually volunteered to have one of his staff members do two replenishment “milk runs” per day. The main milk run is done at night at 21:00 hrs. In another implementation the OR nurses volunteered to replenish the OR suites from the Supermarket, and the Supermarket is refilled by the materials department.
11. Conduct training. Nobody was born knowing Kanban, so you must train your staff. You should focus on two types of training: training for users and training for materials handlers.
12. Kaizen the Kanban system. Once in place, the Kanban system is ready for a process improvement performance review. Conduct a thorough walk-through and solicit input and ideas from materials handlers and operators.
13. Assess Inventory record accuracy. The inventory accuracy goal in a lean environment is 98% or better. The Kanban system should be a help in achieving this.
14. Document and replicate. After you are satisfied with the Kanban system, make sure that you document all the steps you followed along the way, so that you can replicate the system on the next area. From this point on, move deliberately towards having all common items under Kanban control.
15. Perform Kanban maintenance. Changes are continuous, including the introduction of new items, product upgrades and changes in suppliers. Depending on the volatility of change, management of the Kanban system is a daily or weekly responsibility.
16. Involve suppliers. Before turning our attention to outside suppliers, make sure that the Kanban system is working well internally.
These points will get you started and moving in the right direction. Get staff on your side and then implement Kanban in the Perioperative Department first, and then deploy it hospital-wide.