Since Groote Schuur Hospital (GSH) officially opened its doors 80 years ago it has become one of Cape Town’s premier tertiary academic hospitals. From when the first heart transplant was performed to present day, innovation has remained at the centre of the hospital’s ongoing strategy of improving patient care and outcomes.

Despite GSH being a model for excellence in public health, like any other government-run facility it is required to balance a shrinking budget with an increasingly sick patient base. In order to efficiently do more with less, in 2014 GSH decided to implement the Lean Management System in line with the Western Cape’s Healthcare 2030 Strategy, which aims to improve the management of funds, encourage staff to innovate and achieve targets.

Groote Schuur Performance System  

During a specially organised GSH Lean Healthcare workshop, which was hosted as part of Lean Summit Africa 2018, the COO of GSH, Dr Bernadette Eick, explained how in 2014 there were a number of people at GSH who were inspired by the teachings laid out in the books written by US lean healthcare leaders Dr John Toussaint and Kim Barnas. This led to GSH initiating their lean journey, with the support of Lean Institute Africa (LIA), in the Eye Clinic with goal of improving the outpatient journey.

According to Operational Manager for the Eye Clinic, Audrey Sawall (who was one of the first GSH personnel to be involved in implementing lean at the hospital), on average patients had to wait seven hours to see a doctor. This was a great cause of frustration and patient dissatisfaction. By introducing a Daily Management System (DMS) for frontline teams, staff would huddle in front of clearly labelled improvement graphs were they were encouraged to talk about any issues, ideas for improvement and any outcomes of changes they implemented. This system enabled the clinic to make daily minor tweaks in their workflow to improve the patient experience. The system has since been applied in other departments.

In 2015 the term Groote Schuur Performance System (GPS) was coined, which is what the hospital calls their lean-inspired improvement initiative. This includes the DMS and the development of coaches and measurement systems for improvement.

“During this time, management initiated additional projects and we had the first innovation drive, which resulted in the establishment of the GSH Innovation Hub. Then in 2016 we had more learning sessions and started to think about standard operating procedures and got more projects going,” said Dr Eick.

In 2017 a GPS Support Office was established at GSH and senior executives participated in a distance coaching development programme offered by Catalysis, a healthcare organisation founded by Dr John Toussaint that focuses on helping healthcare organisations improve through lean methodologies.

“Now in 2018, we have all these projects but we obviously need to move out of project-mode because the GPS is about developing a culture of continuous improvement and continuous striving to do the best we can with our resources,” said Dr Eick.

Dr Eick went on to explain how the projects have demonstrated that there’s always something that can be done better, no matter how small it may be, which can have huge effects and improve the patient journey through the hospital.

“We have embedded GPS in the provincial strategy, because obviously Healthcare 2030 has got values and principles and we are not going astray from that. Through GPS we are focused on listening to all hospital staff – managers, frontline staff and even porters and cleaning staff – about their ideas and questions on how we can improve. Everybody has something to contribute, and we can only really improve on a sustainable level if we work as a team,” said Dr Eick.

Ongoing improvement

Patient Flow Manager at GSH, Garth Hankey, followed Dr Eick’s presentation with a more in-depth explanation of what lean is and how he is helping to coach staff on the Lean Management System.

“Lean is based on three primary dimensions: thinking, practices and the transformation journey. Lean needs to be customer-orientated and needs to add value to the customer (in this case patient). In order to effectively implement lean, we need to look at the process and determine what steps in the process is considered waste, and then take out the waste and look at the steps that create value for the customer,” said Hankey.

Hankey explained how implementing lean involves a lot of different puzzle pieces that fit together, such as the daily huddles to see what’s happening and what needs to be done to address challenges, and the leadership team to support staff and provide the right resources.

Continuous improvement is only possible if you are able to prove an idea is working by measuring what’s being done on a daily, weekly and monthly basis. This is achieved by analysing graphs and data to confirm or disconfirm an improvement theory. The data being collected on a daily basis can be extremely useful for weekly meetings and monthly review by management to ensure targets are being met and resources are being allocated appropriately.

Gemba Walk

To provide workshop participants with a hands-on understanding of how lean is being implemented on the ground, Hankey escorted the team on a Gemba Walk to the Orthopaedic and Pharmacy Departments to sit in on their daily huddle meetings. Although the two departments have different tasks and patient satisfaction metrics, both have designated areas where clear graphs are displaying their progress.

Groote Schuur Hospital Gemba Walk

GSH Orthopaedic Department task board

The Orthopaedic Department’s main goal is to improve the patient discharge rate. They therefore have a clear graph using red and green to visualise if they are meeting their targets. They also have a table with the possible reasons why patients are discharged late and the number of patients for each reason. During daily team huddles, the on-call staff are able to use this visual management tool to reflect on what’s happening and, with the help of a task board, they can see who’s responsible for what task and when it needs to be done by.

The Pharmacy Department has a similar set up as the Orthopaedic Department; except of course they have different goals, for example improving patient waiting times and stock management.

“Continuous improvement starts when you can identify what is normal and what is abnormal, and then doing something to rectify the abnormal. If the team decides there’s an indication that they aren’t meeting their target, they can start another cycle for improvement. Continuous improvement means trying and experimenting until you get to where you need to be. If you don’t achieve targets try different things, talk to different people and get expert advice,” said Hankey

“Managers play a crucial role in supporting the staff and driving the improvement. It’s therefore important for management to engage with staff on the floor and look at the graphs with them and ask them what’s going on and how they can assist in overcoming any obstacles,” concluded Hankey.

Due to the success of the lean projects at GSH, with on-going support from the LIA the hospital plans to roll out the initiative to other departments to achieve their true north metric of providing innovative, patient-centred healthcare.

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