Lean in Healthcare: Improving a Housekeeping Operation

Posted on Posted in Culture, Featured Article

Find this and other posts of mine at my blog covering lean application in healthcare.  (www.smartleanhealthcare.com)

Healthcare is complex.  There are many pressures competing against any organization succeeding in providing a good patient experience; let alone a great one.

In my time as a health system executive with oversight for a multi-facility housekeeping operation, I can tell you that this is very true in the world of hospital cleanliness. There are many, many challenges to providing an excellent level of service that’ll make the patient and their families feel like they are being cared for in a clean environment. The list is long: staffing issues, technique variation, high turnover, supply chain hiccups, unexpected equipment outages, supply leakage, etc.

The importance of a well-run housekeeping system can not be overlooked. This function is essential to a good patient experience and can have an impact on other facets of the patients exposure to the organization. I had one executive recount to me a story of one of his first stops as a CEO and how the housekeepers had planned a strike. He said, “I found myself with a potential strike from the housekeepers in my facility and knew that it had to be fixed. A hospital can’t run without a housekeeping department.”

The good news is the principles of a lean management system work in this type of operation just as they would anywhere else. There are multiple opportunities to apply these methods and systematic approach to the management of a large or small housekeeping organization.

I found myself with a potential strike from the housekeepers in my facility and knew that it had to be fixed. A hospital can’t run without a housekeeping department.

Some low-hanging fruit to look for:

  • Standard work processes
  • Management Rounding
  • Task frequencies
  • Staff level-loading
  • Managing for Daily Improvement

 

STANDARD WORK PROCESSES

A housekeeping department’s core activity lends itself well to the establishment of standardized work to drive processes. The work product output day in and day out on multiple shift is mostly done on a daily frequency. The cleaning of patient rooms, tidying of public restrooms and emptying of trash receptacles around the facility are basic functions of the operation that must be completed multiple times a day.

The best place to start in the development of standard work is observation.  Observe housekeepers doing their work and take detailed notes regarding the step-by-step process. There are going to be multiple key processes that may belong to the same individual depending on their area of responsibility.

For example, one housekeeper I recall had responsibility for the main facility public restrooms, tidiness of the main lobby and several administrative offices in the vicinity and an outpatient clinic location with occupied by several physician groups. With this many areas that different in scope, there had to be multiple standard work documents available for review. The requirements of a hospital main lobby will differ from that of an outpatient clinic. In turn, the needs of an outpatient clinic is going to differ from the needs of an administrative office.  Therefore, one place to start looking for lean principles within the housekeeping operation of your organization is going to be standard work.

A few different ways to spot a potential need for standardized work in a housekeeping operation are:

  • Challenges related to consistency
  • An unacceptable overtime trend
  • Late arrival of staff in their area of responsibility
  • Variation in look and feel of the work or work product across areas of responsibility

Some common areas to look for standardized work in housekeeping:

  • Cart setup and organization
  • Room turn setup and appearance
  • Operating Room cleaning processes (between cases and end of day)
  • Floor care and maintenance

 

MANAGEMENT ROUNDING

This is akin to leader standard work that involves leadership getting out of the office and to the Gemba to see how work is being done realtime. Without a direct connection to management in the form of rounding, it becomes easy for the operators to deviate from an acceptable standard. Couple the need to set behavioral expectations of staff through regular monitoring with consistent turnover of staff that is regular to the industry and you have a need to institute this type of regular management communication.

Another method my team and I employed was the accommodation of regular townhall meetings with the entire department. This allowed an opportunity to discuss ongoing operational challenges, annual goals, performance and new expectations of the team. It also allowed for realtime, unfiltered feedback from the frontline which proved to be valuable time and time again.

Without this regular connection with management, it was easier for the operational standards to take a backseat to behavioral challenges. In addition, the need for standards also arose of a consistent turnover of staff, therefore, management rounding on seasoned and new employees alike would increase the team’s overall awareness of expectations related to behavior, adherence to the standards and ongoing performance.

Because it became so important to send the same message across multiple locations, the management team developed a rounding process to monitor the state of the facility as they were observed during these events. This data was easily collected using a mobile device and monitored on regular frequencies with multiple levels of the organization.  This allowed for targeted conversation with staff on areas that were improving and areas that presented opportunity leading to a more efficient and effective application of the management rounding as a resource.

Some indicators that a manager rounding process is needed include:

  • Variation in performance on key survey metrics
  • Anecdotal evidence of less than optimal performance that persists and becomes a pattern
  • Supply costs or overtime that trend up over a period of time
  • Observed deficiencies that are clearly accounted for in standard work as unacceptable

 

TASK FREQUENCIES

The large majority of tasks completed by personnel are consistent across any type of housekeeping operation.  Because of this commonality, the industry has published several iterations of a manual that lists how long a task should take to complete.  It will even account for how long the task should take given the kind of equipment used to do the work.

This allows housekeeping operations to plan the way in which they staff a location by doing an assessment of every task that needs to be completed.  A housekeeper’s area of responsibility could then become multiple locations that are separated geographically, because the the task frequencies dictate how many minutes of capacity are available.

This presented itself as an issue in the hospital locations I managed when dealing with room turns and keeping up with demand.  One way to plan for demand is to have a good handle on how long it is going to take a staff member to complete a task or cover an area.  By standardizing the frequencies that areas and items are cleaned, the department is able to plan staffing more efficiently and effectively.

So, a task frequency sheet for a hospital would look like a list of areas and or tasks that need to be completed categorized into major areas of work: general cleaning, floor care, terminal (or end of day) cleaning, trash removal, windows, stainless steel, etc.  Each task would then have an identified frequency to follow when planning work.  For example, patient room cleaning would occur daily and as needed.  The frequency then for that task would be counted as daily and the department supervisor would need to ensure that there is staff to cover this work daily.  Alternatively, floor care might have a frequency for burnishing (polishing) the floor of twice a week, but a daily need to sweep and mop.

Some key frequencies to ensure are available:

  • Floor Care – (sweeping, mopping, scrubbing, burnishing and full refinishing)
  • Waste Removal – (trash, biowaste, sharps, linens removal for individual areas and also for complete removal and processing at the facility level)
  • Patient room cleaning – (daily cleans, trash and waste check-ins)
  • Procedural areas – (verify make-up of what’s involved in an in-between case clean versus a daily terminal clean)

 

STAFF LEVEL LOADING

I have observed in multiple facilities that the influx of admissions will, rarely, if ever, coincide with the outflux of discharges.  Admissions will start ramping up around mid-morning and peak around the evening time, while discharges don’t begin to pick up until mid-afternoon and peak in the evening time.

This creates a demand issue for many housekeeping operators because as the admissions increase there will come a time in the day that a surge of discharges are processed requiring those rooms to be cleaned.  This may mean a housekeeper with an area to cover will have 4 to 5 discharges placed in the work queue within a span of 30 minutes.  These discharge responsibilities are on top of her daily tasks assigned through area assignments and the frequencies discussed above.

In order to counter this issue, and make an attempt at balancing workloads, a review of normal shift patterns and staff available to complete the tasks at hand is employed by housekeeping managers.  An advanced analysis I performed within my own operation involved gathering six months of admission, discharge and transfer data.  WIth that data, we created a graphical representation of how many in each category came through the EMR via orders by hour of the day.  We were then able to take and compare that data to a graph of bed clean requests by hour of the day.  This graphical analysis and the interpretation led to the team determining that a small cohort of staff would be deemed a “discharge team” and would handle only room turns.  Their capacity was determined by using task frequencies, industry guidelines on how long the room turn should take and comparing it against the average amount of requests coming through the system by hour of the day.

This technique can also be used when analyzing the workload of staff assigned to floor care.   I have observed a tendency among contractors to want to have floor care personnel visible during the day shift.  This results in a patient and their families walking down a hallway beside a floor scrubber or buffer.  This can be disruptive to visitor flow, a noise disturbance and it introduces a risk of fall with slick floors.  The facility is primarily void of visitors in the nighttime hours allowing for large areas of space to be cordoned for the purposes of floor care in a more efficient use of resources.   If a department can find the right staffing complement to perform this maintenance on the night shift, it is recommended.

Areas to look for level-loading opportunity:

  • discharge cleans
  • floor care processes
  • support area cleaning
  • supply restocking

 

MANAGING FOR DAILY IMPROVEMENT

I have found that most housekeeping departments will have a staff huddle at shift change. It allows for handoff of responsibility for staff with a common area, handoff of shared equipment and management communication. It’s a good practice, and it’s one most departments already employ.

Ensuring there is a standard process across shifts and between members of the management team is key. The use of a daily management system can assist in standardizing the conversation.

A few elements of a huddle to look for:

  • standard agenda
  • performance metric review
  • key process review
  • active engagement of staff

 

Find this and other posts of mine at my blog covering lean application in healthcare.  (www.smartleanhealthcare.com)