Toyota work methods applied at General Hospital

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S.F. General Hospital and Trauma Center rebuild project
PHOTO BY MIKE KOOZMIN / S.F. EXAMINER FILE PHOTO

San Francisco’s Department of Public Health has a $1.3 million contract with Seattle-based Rona Consulting Group to implement the Toyota Management System, a workflow methodology based on the auto-manufacturing model, at San Francisco General Hospital.

This new model, which aims for greater workflow efficiency, is being implemented just as healthcare staffers raise concerns that staffing levels at SFGH are dangerously low.

“Nurses often work through their breaks, and they stay after their shifts to get charting done,” said David Fleming, a registered nurse who has been at SFGH for 25 years. “I think nurses are getting the job done – but they’re at the edge.”

A group of healthcare workers spoke out at the May 7 Budget & Finance Committee meeting, during which supervisors discussed the DPH budget. Public employee union SEIU 1021, which represents healthcare workers, is in the midst of contract negotiations but Fleming said they had been grappling with reduced staffing for awhile.

According to a contract request to the Health Commission sent anonymously to the Bay Guardian, DPH entered into a 24-month contract with Rona totaling just over $1.3 million, for the purpose of implementing the Toyota Management System methodology as part of the transition to the new SFGH acute care facility, scheduled to open in December 2015.

The Bay Guardian received a copy of the contract request via BayLeaks, which uses encryption software known as SecureDrop to enable sources to anonymously submit documents.

The $1.3 million came from “General Funds (Rebuild Funds)”, according to the contract request. In 2008, voters approved Prop. A, funding the $887.4 million General Hospital rebuild through general obligation bonds. Use of the voter-approved, taxpayer-supported funds is restricted to hospital construction under a state law that limits the use of bond money to specified purposes.

However, Iman Nazeeri-Simmons, chief operating officer at DPH, said funding for the Rona contract came from a “hospital rebuild transition budget,” which she said provides for needs beyond construction costs.

Specialized consulting to educate hospital staff in the ways of the Toyota Management System doesn’t come cheap. A single meeting between the consultant and “key leaders” to “discuss needs and develop operational project plans” cost $25,225, the document showed. A one-day “visioning session” facilitated by the contractor was priced at $16,814. Five-day workshops fetch Rona $42,032 each. Based on estimates included in the contract request, the consulting firm would earn the equivalent of $4,707 per day.

The $1.3 million consulting contract was awarded even as unions remind city officials of staffing cuts during the economic downturn in 2008 that still have not been restored.

Here's some video testimony from hospital staffer Heather Bollinger regarding how tough things can get at the General Hospital's trauma center. "We do have staffing issues, and they do affect patient safety," she said in public comment to the Health Commission on April 15.

Nato Green, who is representing nurses as a negotiator on behalf of public employee union SEIU 1021, described the staffing levels at SFGH as “unsafe and unsustainable.” There are currently 90 vacancies for nurses that haven’t been filled, he said. That’s a 14 percent vacancy rate, Green noted -- typically substituted with traveling nurses, temps, and overtime labor.

Nazeeri-Simmons said the consulting was necessary for the transition to the new SFGH facility, for “doing it in the best way, and understanding there’s a completely different physical environment over there.” Rona is a pioneer in healthcare performance improvement, she said, and they are “leading us in very interactive workflow designs that are simulation-based,” geared toward “maximizing value and driving out waste.”

But does “driving out waste” translate to staffing cuts? “It certainly hasn’t happened here,” Nazeeri-Simmons responded when asked about that. Instead, the consultants have helped management to “right-size services to meet the demand,” she said, noting that wait times in urgent care had been significantly reduced as a result. Decisions such as using a portable X-Ray machine that eliminated the need for patients to walk ten minutes across the hospital grounds had dramatically reduced wait times, she added.

“We need to make sure the staff are working to the highest of their capability,” she added.

Heidi Gehris-Butenschoen, a spokesperson for Rona, said the goal of transforming work practices under the Toyota Management System is to improve patient care. Asked whether the consulting tends to affect staffing levels, Gehris-Butenschoen said, “That’s really up to the hospital. It’s definitely in our workshop not something we focus on. The Toyota system is not about cutting heads at all.”

SFGH has been working with Rona since July 2012. One of the company partners was formerly the CEO of Productivity, Inc., which advised “large-scale transformations for Fortune 100 companies,” according to the contract request. The workflow methodology is rooted in Lean principles, integrating a “just in time” staffing concept that’s been applied in corporate settings such as Walmart.

The Health Commission approved the $1.3 million contract at its Dec. 17, 2013 meeting as part of the consent calendar, which is summarily approved by a single vote.

Fleming, the RN, was skeptical of how much the Lean system had actually accomplished. They had literally “rearranged the furniture” since the program was implemented, he said, and observers had silently monitored staffers’ activities.

“When we work with anyone, we go out to the gemba, and we observe,” Rona’s Gehris-Butenschoen explained, noting that gemba refers to “the place where work happens.” The observations help hospitals identify where waste can be reduced, she added, such as moving a supply cabinet if time is being taken up by crossing the room to get to it.

But Fleming said he wasn’t convinced that applying a corporate efficiency method, borrowed from manufacturing, would provide the greatest benefit in a healthcare setting.

“We are not taking care of cars on an assembly line,” he said. “When it comes to another human being’s body, I don’t know that faster is necessarily better.”