Dose 2: At the “Gemba”
Observation is key to applying lean to Covid-19 vaccination. A week last Saturday I felt privileged to observe the vaccination process with the people working the front-line. Privileged because we have been starved of so much direct contact over recent months, because I love to be at any workplace and because I met fantastic people (team members and patients.) I came away with lots more questions but with the information I needed to tell a story.
There has been a mixed reaction to the performance of the U.K.’s vaccination process. The glass half full folk talk about how much better we are doing than everyone else. The glass half empty folk say that when everyone is having a bad time of it, having a less bad time than everyone else isn’t much consolation. Whatever your stance most agree we are excited (probably relieved) that we have a vaccine. If we are lean thinkers, we see opportunities for doing things better by applying lean to Covid-19 vaccination.
My second article to inject lean into the process (pun intended – a first shot and a second shot) builds upon my last piece https://www.leanuk.org/a-shot-in-the-arm-applying-lean-thinking-to-covid-19-vaccinations/ about how lean thinkers define problems, organise work and develop capability across the enterprise and supply chains. In this article we would go to “gemba” (a Japanese term used across Toyota that describes the importance of going to the “real or actual place” – where value creation is taking place) to observe the process. The underlying thinking is to grasp a current situation. Ensure we have a good process. Celebrate the good things and make visible the problems people have.
It looks likely that Covid-19 will be with us for many years to come. The folk close to the work (in hospitals, hubs, GP practices and pharmacies) have knowledge of vaccinating thousands of us every year. But to beat the virus we need to vaccinate on a scale never seen before. The question we asked ourselves was how can this process be scaled up and the work made easier to do, at the same time? Every location will have challenges. So, how can learning be captured during this process? Potentially there is a common path to learning to improvement well known by lean thinkers. If we don’t use it, the front-line will be overburdened. That is neither sustainable nor respectful. Things can be done. Kaizen (continuous improvement) will be key. Lean can be applied to Covid-19 vaccination.
Visiting the Vaccination “Gemba”
The “gemba” I visited on Saturday was a local GP practice. I have quite a few friends involved in front line healthcare. I was sure that all possess the capability to do the work, but not sure how it was organised. Would it be done in a way that is most valuable for the patient while at the same time easiest for the worker? The practice had received 400 doses of the Oxford AstraZeneca vaccine. Saturday was their third day vaccinating their over 80-year-old patients.
Booking staff had telephoned patients and reserved 110 appointments for Saturday. Each vial of Oxford AstraZeneca contains 10 doses (with a possible extra 11th dose) therefore if everyone attended their appointment there would be no wastage – once a vial is opened it must be used within a period of 6 hours. Each patient was scheduled to arrive at 2 minute intervals. They would be greeted at the reception desk and asked to go through to one of 4 clinic rooms. Three of the rooms had a clinician delivering the vaccine and an administrator loading patient information into the computer database. In the fourth room a clinician carried out both the clinical delivery and the administrative tasks.
I was to arrive on site for 08.30am. They would prepare (set up each station and the process) before receiving their first patient at 09.00am. In our part of the world, it had snowed overnight. At 08.40am I found that my first task was to clear snow and grit leading up to the front door to make the entrance safe. Set up involved a discussion of the door-to-door patient flow – from entrance to exit. Vaccinators moved equipment to their clinic rooms, rearranged furniture into the way they wanted it and stocked up on the items required to administer the vaccine.
Usually the practice has a complete one-way flow with a separate entrance and exit. However, the exit opens onto the staff car park which was slippy. It was decided to enter and exit through the main door as there would be less risk of trips and falls. Meanwhile administration staff logged onto their systems – the GP practice database where appointments had been pre-loaded with patient information and a national database called the Welsh Immunisation System (WIS) which stores records of everyone in Wales.
All preparation tasks were “external” to the activity of giving a vaccine. All needed doing before a patient receives the vaccine. They had planned to start the process at 08.30am so they would be ready at 09.00am. They were. Whenever I observe set up I ask myself the following questions:
- What is the standard for setting up – what were the team trying to achieve?
- What problems did the team have getting ready?
- How can the work be made easier to do?
- Is preparation work distributed to the most appropriate team member and is it equally divided between team members?
- Would being “more visual” in the way they displayed the work help?
Patients Are Waiting at 09.00am
Across the globe, there is a joke that “Brits love to queue.” In pre-Covid times my travels have taken me all over the world. You rarely see as orderly a queue as you do in the UK! By the time the front door opened at just after 09.00am a line had formed. The first patient was greeted at reception and asked to walk through the waiting room via a one-way system to the clinic rooms. The practice manager was in the waiting room directing patients through to the clinic rooms. This was the start of the morning flow.
Initially I just observed. This wasn’t an automotive plant, or one of my lean car dealers where I could look at the standardised work sheet to see if the process was operating as designed. This work is done as 99% of the world do their work. With care, conscientiously and with consideration for others. Lean thinkers have learned from Toyota that work can be documented so that anyone see whether it is being conducted as designed. This visibility makes the activity of improving the work a more structured process. Having observed for a few minutes I now needed to visualise what I could see.
Seeing the Work
Now I could see the work. It involved patients arriving at a desk. Being greeted, asked their name and marked as arrived in the booking system. They were invited to sanitise their hands, given a fact sheet and directed into the waiting room. They were then directed through the door and sent to the next free clinic room. I noted the steps, documented them and timed 10 successive patients. Why? To further “learn to see” the current condition. What was happening? Did it happen every time? Did the patients all follow the same steps? Is there a big variance in the time each patient took? As I observed I documented what I saw on the Process Study Sheet.
After just over 2 minutes the first patient emerged from a clinic room, vaccinated. They then either waited 15 minutes in the socially distanced waiting room or left immediately.
What really is the work?
I’d now been observing 45 minutes, but I hadn’t seen the value creating process. For the anorak lean thinkers amongst those reading this – you are aware that generally we start observation at despatch/shipping/the last process in the system. That is the waiting area in this case. We then follow the process upstream. However, the customer is embedded in the process, which starts at the front door. The booking sets the pace of entry and therefore it’s ok to start here. I could now go and observe the detailed steps required to give the vaccine.
I sat, socially distanced, in the corner as a lady came into the clinic room. She was greeted by the clinician and asked to give her name and date of birth to the administrator who found her on the computer and confirmed her details. This built-in quality check started a sequence of recording information in the database. The clinician then took over, explaining that the vaccine needed to be injected into her arm and asking whether she was left or right-handed and which arm she preferred the injection to be given in. Her clothing was assessed – Saturday was cold, it was snowing outside so most patients arrived with multiple layers of clothing on even though they had done as asked during the booking process and were wearing a short-sleeved top underneath!
The lady was directed to sit down, and the clinician explained what the vaccine was, checked there were no contraindications to the patient receiving the vaccine and asked for consent to give it. A syringe and a swab were picked up and an explanation given that the patient would feel very little. The vaccine was injected. The syringe and swab were disposed of and a discussion of how the patient could feel over the next couple of days was explained.
The administrator then gave the patient a vaccine card, an after-effects leaflet and details of how they would be contacted for their second dose discussed. The patient was asked to re-dress and it was explained that they should not drive for 15 minutes and offered a seat in the waiting room. As the patient left the room, the clinician wiped down the chairs and sanitised the area ready for the next patient.
Process Study Tips
When completing a Process Study Form don’t include any obvious waste as work elements. They are not part of the work. Hopefully that way you can eliminate some waste on paper before changing the process. Some guidelines:
– Don’t include walking for team members as a work element.
– Do not include any out-of-cycle work as work elements.
A good example in this case would be filling a syringe with vaccine. Why? Because out-of-cycle work destroys continuous flow and makes it impossible to maintain flow to take time. These tasks need to be done but should be separated to support personnel.
– Don’t include people waiting for machines as a work element.
Our workbook Creating Continuous Flow is a great resource for those wanting the develop much better work processes. It can help anyone apply lean to Covid-19 vaccination.
Writing Work Elements
With the work elements defined, the next stage is to time each work element. When I first learned to do this (almost 30 years ago) all work had to be observed in real time. These days technology can help enormously. Video is particularly useful as the team doing the work can see a recording of their activities. This eliminates any disagreement about what is done/not done and leads to much richer discussion. The dialogue changes about what needs and can be improved. However, using video in this setting would have led to extra steps. Patients would have to give consent, so I recorded the good, old fashioned way. It was good practice for me but arguably not as good a learning experience for the wider team.
What do we see when we do a Process Study?
The process study form gives us facts. Not opinion, not “we usually do …” It’s like holding up a mirror, enabling us to see the process. The vaccination process involves people. It’s not entirely mechanical as a person (the patient) is integral to the process. One patient may have lots of questions, another may be frail and need more time, another may be hard of hearing and so on. However, the process study form shows us which of the steps appear to be repeatable with consistently similar times, and which have more variation.
When we do this in most environments, work is rarely done the same way every time. In customer facing areas it’s often given as a reason not to try to have a repeatable process. Non repeatable processes cause a huge problem – they make it very difficult to plan and almost impossible to flow. To get an understanding of why it’s so important to “standardise” the work take a look at our free Standardised Work Knowledge Course.
During the observation it became apparent that some work elements are entirely repeatable, others more difficult to make repeatable. For example, wiping down after a patient is repeatable, discussing potential issues post vaccination more difficult to make repeatable as questions may arise. Even in this second case, techniques can be used to make the element more repeatable. Leading the conversation, thinking about the sequence of the information and explaining the most typical questions can help.
Looking at the length of time of the process steps also prompts more questions. The way in which we question whether a process is done by the most effective means can be seen in the image below:
By asking these questions (5W1H), in turn, one can agree whether a step is value creating or not, whether it should be combined with other steps, rearranged or simplified. These are really the four things you can do to improve the safety, quality, delivery or cost of a process. A great example, looking at the Process Study Form is the “undress” step. It’s the longest single time element. Because it was cold (snowing) patients had wrapped up well. But three out of ten were very prepared. They had taken their coats off before entering the clinic room and were wearing short sleeves as they had been asked during the booking process (another 3 also did but undressed in the room) – hence the difference in time.
In another example, reception handed patients a fact sheet about the vaccine. During step 9 the patient was given two more pieces of paper. Firstly REG 174, Information for UK Recipients is a comprehensive explanation of the vaccine, including its purpose, what a patient needs to know before being given it, how the vaccine is given, possible side effects, how to store the vaccine and the contents of the pack. Secondly an NHS Wales bilingual information sheet “What to expect after your Covid-19 vaccination.” On presenting these leaflets to patients four out of the first six said they already had it. They thought what they were about to be given was what they had already received at reception. Changing the phraseology eliminated the confusion and discussion, shortening the time.
Eliminate, Combine, Rearrange & Simplify
Whilst time and purpose resulted in us not reconstructing the Process Study Form to eliminate, combine, rearrange or simplify the steps – that is really the point of looking at work in such detail. The correct way to do this is to give the front-line the skill to look at their work – they will come up with much more appropriate countermeasures than the centralised staff, improvement experts and outsiders.
I wouldn’t be so presumptuous to suggest what should be improved here – and neither should the reader. Afterall readers will not have visited the gemba, so, how could they? Dictats (or suggestions) from on high or from external actors are rarely followed. However, I was interested in the capacity of the system. To understand this, I did a rough calculation of the “lowest repeatable time” of each work element as the process was observed. Note the “lowest repeatable time” isn’t the fastest time – it’s the time a team member could safely repeat the work. By adding each element’s lowest repeatable time together one gets a realistic time to complete one vaccine. In this case it works out to be 2 minutes 45 seconds per vaccination.
Patients are booked to arrive at 2 minute intervals. If nothing were improved, but this time used to plan how many clinics are required, then 2 clinics staffed by a vaccinator and administrator (not 4 – all be it they were training) would be needed. The calculation here is Total work Content/Takt = No of people (in this case clinics – each operated by 2 people.) The point here is that anyone can throw people at a problem – but understanding the total system is necessary to optimise flow.
Developing Capability Across the Supply Chain: Pull not Push
Arguably, the vaccination process hasn’t been the “biggest” problem. Getting supplies has. In Wales GPs haven’t been given either firm delivery dates or quantities of vaccines they will receive. This means they can only plan clinics once they have received the vaccine. This increases the lead time. However, knowing the cycle time is key to design of the supply chain. By understanding the work, it is possible to calculate the number of clinics required, overlay how many centres are needed and then design the delivery system.
If Covid-19 vaccinations are to be a part of every-day life we aren’t going to be able to rely on the good-will of volunteers nor are we going to be able to add such an endeavour on to the ever-growing list of activities we require healthcare professionals to do. Resources are already stretched, so thinking through the work to be done and the design of the supply chain is an integral part of the activity required moving forward.
Outside of Covid-19 vaccines, NHS supplies currently make weekly deliveries to surgeries in Wales. For example, if a GP places an order on Monday, they receive their supplies one week later, on Wednesday. Such a system is even less responsive than the supermarket supply chain we encountered in the 1990’s when we started research with Tesco. That was, at least, a daily system of ordering and delivery. The lessons from our research into Toyota’s spare parts distribution system in Japan (that was expanded globally) was used as the inspiration for experiments across Tesco’s supermarket distribution system.
The principles spread across the industry and are used in fashion retailers such as Zara and in the Amazon fulfilment system. The purpose is simple – provide exactly what the customer wants, when they want it, in the quantities wanted. To do that organisations must compress the order to delivery lead time and deliver small quantities regularly, just in time. This removes peaks and troughs from the supply chain, reduces the amount of stock required to be stored and dramatically increases the velocity of product delivery. A good summary of the benefits vs myths of JIT are available here.
To implement this cost effectively (and it will be cost effective – needing far less stock than a traditional push system) health care supply providers need to map the extended value stream. This needs to be done NOW to avoid supply issues in the process moving forward. Without such exercises, the opportunity to develop insight will be missed. I am sure that the front line will deliver – but will have done so with much overburden. We will get through this current crisis but will not have questioned the underlying thinking of how we are organised to mass vaccinate.
We must get ahead of the issues we’ve encountered during the pandemic. The problem to solve is how to increase the velocity of the total process and vaccinate as soon as possible to save lives, then to set up processes to be able to do this safely, in the shortest possible lead time in the future.
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