“What kind of care would I want for a loved one who is fighting cancer?”

This is the question that Julia, an outpatient clinic nurse at Cancer Treatment Centers of America (CTCA), asked herself as she observed the following process:

• Mrs. Smith, a patient, arrives early to the clinic to meet with her oncologist, Dr. Mark.
• Dr. Mark is finishing up an appointment with Mr. John, so Mrs. Smith is handed a pager and asked to return to the clinic when the pager goes off.
• Mrs. Smith proceeds, with pager in hand, to the cafeteria for lunch.
• Dr. Mark finishes his appointment with Mr. John and the clinic receptionist triggers Mrs. Smith’s pager to alert her that Dr. Mark is now ready to see her.
• Mrs. Smith does not return to the clinic because her pager never goes off.

Ideally, using a pager in the clinic should be an excellent process. As patients arrived for appointments with a medical oncologist, they checked in with the clinic receptionist. If the physician was finished with prior appointments and ready to see the current patient, the patient immediately proceeded to the appointment. However, if the medical oncologist was with another patient, the arriving patient was given the pager, which would send an alert about when the physician was finished. Rather than restricting patients to the clinic waiting room prior to their appointment, the pager system empowered them to manage their time as they saw fit – they had the flexibility to go for a walk on the premises, dine in the cafeteria, return to their on-site living accommodations for a short nap or participate in one of the hospital’s many activities. Yet 38 percent of the time when the pager was triggered, the patient never received the page.

After having to search physically for several patients, it became evident to Julia that the pager process must be re-evaluated; she realized it must evolve into one that is more patient-centered. The following case study illustrates how Julia worked to improve the patient notification process, and serves as an introduction to the Lean efforts taking place at the Cancer Treatment Centers of America.

A Culture of Lean

The question “What kind of care would I want for a loved one who is fighting cancer?” is one that employees (known as stakeholders at CTCA) ask themselves every day. Stakeholders refer to this type of care as the “mother standard” model of care, which is the essence of CTCA.

Although CTCA was created in 1988, the origins of CTCA’s treatment philosophy go back to the early 1980s following the tragic death from cancer of Mary Brown Stephenson, the mother of CTCA founder Richard J Stephenson. Disappointed in what were regarded as world-renowned cancer treatment facilities that were more focused on the clinical and technical aspects of cancer treatment rather than a multidisciplinary approach, Stephenson embarked on a mission to find the most advanced and effective treatments available under one roof; hence the birth of CTCA.

The spirit of challenging the status quo while placing patients at the heart of all efforts every day is the foundation of CTCA. This spirit is what drove the organization, as well as stakeholders, to adopt a culture of Lean. Through Lean thinking, CTCA has learned methods that allow stakeholders to create an environment to do more valued-added activity with less waste. The Lean approach to performance improvement dictates a systematic way of evaluating a process to meet the needs of the customer. With CTCA’s commitment to creating a culture of continuous improvement, the application of Lean provides a platform for ensuring the fulfillment of this dedication.

Empowering Stakeholders

CTCA strives to create a culture in which quality improvement becomes a habit for all stakeholders. In order to fully achieve this goal, CTCA recognizes that it must first begin by empowering stakeholders to make a difference. One aspect of Lean adopted at CTCA is the A3 performance improvement program, which is designed to empower stakeholders with the tools necessary to improve their workplace and work processes.

A3 is a Lean tool based on the principle of the plan-do-check-act cycle that can help individuals develop solutions to problems using a single sheet of A3-sized paper (roughly the dimensions of a tabloid newspaper). The method can be used for process improvement, enhancing turn-around times, increasing efficiency and reducing waste. The A3 program empowers stakeholders to take ownership and make improvements in their own work areas.

An empowered environment is one in which stakeholders have accountability, responsibility and decision-making authority that is appropriate to meet our patient’s needs. When someone is empowered to make decisions about how work is done, then quality, service and productivity will constantly improve for patients.

Leaning on Peers

CTCA adopted this empowering philosophy when building the training infrastructure for the A3 program. Recognizing that subject-matter experts are best for creating process improvement solutions, CTCA refocused this concept through the support and teaching components of the A3 courses. However, the limited staff of Lean practitioners (usually one or two per hospital) was creating a coaching bottleneck for students and valuable A3 projects. Using the Lean methodology, coupled with the CTCA spirit of challenging the norm, a new component was added to the A3 regimen: stakeholder-to-stakeholder coaching.

At CTCA, a coach is assigned to each A3 project. A3 coaches, or mentors, are CTCA stakeholders who know Lean well, as they have each previously completed an A3 course and project. Having this background and understanding of the process, they are able to empathize and provide counsel for stakeholders who are learning and applying the A3 curriculum for the first time. Realizing the importance of empowering all stakeholders throughout CTCA, A3 coaches have volunteered their time in supporting stakeholders through the A3 process – not only providing a sounding-board throughout the entirety of the project, but also attending A3 classes and assisting in data collection.

The focus of an A3 coach is to assist the stakeholder in developing a successful A3 project. A coach does not simply tell the stakeholders what to do; rather, they provide advice and ask appropriate questions when warranted. Ultimately, coaches act as consultants for each A3 project. Often, when working on an A3, a stakeholder may feel inclined to solve the problem early in the process before completing each step. This is when a coach is needed to help the stakeholder focus on the process of the A3 one step at a time. If a stakeholder focuses on the solution of a project too soon, for example, the root cause could be missed and the redesign of a future state may not be sustainable over time.

In addition to providing general direction throughout the process, an A3 coach may also assist with direct observation and mapping of the current state of a process. Often stakeholders feel overwhelmed by what they cannot easily control, and the project management and leadership role is new to them. The coach is usually from an entirely different department from their mentee, lending the project owner a fresh set of eyes and ears. As a new observer to a process, the coach can more-easily identify waste, variations, defects and poor practices, providing clarity to the project owner.

The Power of Coaching

Let us return to Julia’s project.

Julia was observing a patient process that had many visible defects. The process, once intended to empower patients, had transformed into one that created frustration and unwarranted stress and waste for patients, caregivers and stakeholders. While Julia continued to search for patients throughout the hospital, she began to conceptualize alternatives to strengthen the process.

As she analyzed the current process, Julia thought about the following: Is there a way to reduce the non-value-added time spent searching for patients? What process would alleviate patient exhaustion and stress caused by the defective pagers and, in some cases, reduce missed appointments? Is there a way to streamline the process to both empower patients and deliver their care in a timely manner? These questions were what introduced Julia to the world of Lean.

True to the structure of the CTCA A3 program, upon enrollment in the eight-week course, Julia was assigned a coach, Colleen, to assist her throughout her project. Colleen was extremely familiar with the A3 program, as she had completed several A3 projects herself. Providing insight from past experiences, Colleen was able to coach Julia effectively through the A3 steps (such as documenting a problem statement, objective statement, current value stream map, root cause analysis, future value stream map, implementation plan, quantifiable results and follow-up plan) required to find a solution for the faulty pager system.

Throughout the duration of the project, Colleen and Julia worked closely to identify the root cause. Rather than jumping to an unsustainable solution, Colleen coached Julia through the drawing of a current value stream map and data collection plan required to support Julia’s problem statement. Using 27 of the current pagers, Julia and Colleen performed tests throughout the hospital, gathering data on the number of times the pagers worked when sounded. Together, they visited the cafeteria, the hospital grounds and the lobby, as well as other popular areas throughout the hospital.

After collecting data, it was evident that the pagers worked only about half of the time in most areas and not at all in other areas. In fact, pagers only worked 7 percent of the time in the cafeteria – the main area where waiting patients frequented. By going to gemba (the Japanese word for “workplace”) and making observations, Julia and Colleen determined that the root cause of the malfunctioning pager system was that the repeaters that were plugged into wall outlets were not consistently picking up the appropriate signals from the pagers. This helped confirm the need to research alternative solutions to the process.

Julia and Colleen also learned that the hospital’s transportation department utilized a different pager system, which was operated via satellite and did not need to have repeaters plugged into wall outlets. Using this knowledge, Colleen and Julia tested a few of transportation’s pagers throughout the facility. Much to their surprise, the pagers worked 100 percent of the time, in all areas of the facility. Additionally, because the pagers were supported via satellite, this system provided patients with the extended flexibility of leaving the facility during their wait, creating a true patient-centered process, which the previous system lacked.

Upon implementation, the new system increased the rate of functioning pagers from 62 percent to 100 percent, and it decreased the amount of time stakeholders had to search for patients from 45 minutes a day to zero minutes. Although there was a minor cost that was needed to purchase the new pagers, the non-value-added time of stakeholders searching for patients was eliminated and this savings was enough to pay for the pagers in less than two months. Most important, patients were thrilled because they no longer had to worry about the unreliability of their pagers, which ultimately enhanced patient satisfaction.

Positive Feedback

The A3 process itself is designed to provide a platform for stakeholder empowerment, and the unique addition of a coach throughout the program provides the inspiration and motivation necessary to support stakeholders through their journey of assisting patients.

“Being part of an empowered culture, we have a voice in any changes we see fit,” coach Colleen adds. “We believe that there is no one better to identify problems in our own areas of expertise than the stakeholders who do the actual work. We are most familiar with the problems that arise in our jobs and with the needs of the patients we serve. Stakeholders who continually think about how to do the job better and act on ideas will assist CTCA to be more responsive and proactive to our patients’ needs, and our A3 program allows all stakeholders to feel empowered to make changes.”

Pictured above are Colleen Coyne (left), the A3 project coach, and Julia Seidler, the project leader, holding onto one of the new clinic pagers.