CASE STUDY – The CEO of a hospital in Johannesburg looks back to the last five years to reflect on a lean healthcare transformation that is creating positive outcomes for patients.

Words: Grey Dube, CEO, Leratong Hospital – Johannesburg, South Africa

To read our interview with Dr Dube, click here

The South African healthcare industry must look after 53.7 million people, 84% of them in the public sector. The remaining 16% of the population has private health insurance and spent 47% of the total health expenditure of R294 billion in 2015 ($23 billion at the exchange rate of the time). It’s clear that the public healthcare system has to do far more with far less. In this article, I’ll tell a little bit of the story of what has been happening in one busy 1,638-staff, 855-bed public hospital on the western outskirts of Johannesburg – Leratong Hospital, where I serve as CEO.

We are a “Referral Hospital” for two District Hospitals, 45 Clinics, 4 Satellite Clinics, 10 Mobile Clinics, a Psychiatric Hospital and 17 Clinics from the Johannesburg metro area (79 Service points in total, 80 when Leratong is included). While a key component of the local healthcare system, our hospital serves  a largely poor community. The scene outside the entrance to a hospital (which you can see below) is one of peri-urban poverty.

In the year to March 31, 2019, Leratong Hospital saw 279,864 patients (of which 54,202 in casualty). The total number of deliveries (mothers admitted) was 6,605, and in that year 6,724 babies were born here.

In mid-2014, the Lean Institute Africa proposed to the Gauteng Department of Health an innovative improvement plan focusing on hospitals. After discussion, debate and a tender process, the proposal was accepted. In November 2014, the Leratong Hospital was included in a “cohort” of four hospitals to begin an improvement approach based on lean thinking. Five staff members, including me and other senior staff, attended training workshops and a rapid improvement event (RIE) at another hospital before we embarked on our own, week-long, RIE in January 2015.

Three “model line” areas were selected for the RIE, chosen to trace the typical outpatient journey: Patient Records, Outpatient Clinic, Outpatient Pharmacy. Significant improvements were made, even in the RIE week. For several months after that, a Lean Institute Africa coach worked with both management and staff to develop visual management boards, and stabilize and standardize the work of each of the three model lines. Lean Insitute Africa worked tirelessly to develop internal capacity: at the end of 2015, we ran our own RIE in the X-ray department. We learned a lot and, because we did it ourselves, we grew in confidence.

A couple of examples of the documentation created in the selected areas during the initial RIE follow (another example is the outpatient pharmacy - pictured in the main article picture). The first one is patient records, the second one the Outpatient Clinic.

Before long, value stream mapping, visual management, 5S, A3s and PDCA became part of the way we work. My managers and I are obeying a “no meeting zone” routine before 10am each day, so that we can be out on the gemba, supporting our front-line staff in getting the day off to a good start.

Here are some of the results over the first 31 months of our transformation:

In August 2016, together with colleagues from hospitals around Johannesburg, I had the privilege of spending a week with ThedaCare in Wisconsin, USA. It was inspiring to see a mature lean healthcare system! Even more exciting and rewarding has been the collaboration that trip initiated among ourselves, Catalysis and Lean Insitute Africa. Starting in January 2017, we have worked on leadership behaviors and developed a management system aligned with True North objectives. Catalysis provided a syllabus of readings, videos and monthly coaching calls, whereas Lean Institute Africa provided more frequent calls and monthly gemba visits.

In the past 12 months, we have seen significant progress in both management behaviour, staff problem solving, and clinical outcomes. Leratong serves a poor community, with many emergencies – including maternity complications. Mothers in labour frequently arrive in desperate circumstances, their babies very vulnerable. The staff in our neonatal unit are often in the front-line of these emergencies. As part of the Catalysis/Lean Institute Africa/Leratong collaboration, the neonatal unit has turned into a new model line for us over the past 18 months, with the staff embracing the lean approach with relish. The graph below shows infant mortality rate in our neonatal unit: while it reflects tragic outcomes that are of great concern to us all, it all shows a positive trend that encourages us to persevere and convinces us of the power of lean thinking.

Managing this hospital in the testing conditions that Leratong faces is a challenge, to say the least, but I used to receive numerous complaints from patients and their families from what are now our model lines, whereas now we almost never do. Positive patient feedback is now much more common. My staff and I are very encouraged by the results from the lean journey we have been on since November 2014. Some 300 staff members have now received at least some lean training.

The following graphs show waiting times in a number of departments. While they clearly show recent progress, they are also proof of how difficult change is to attain and sustain. If we needed extra evidence that lean is a long-term commitment and that perseverance is necessary, we need to look no further.

Our work is catching the attention of senior public sector executives, including some working outside of healthcare. We are increasingly asked to host visits or give talks to senior civil servants. Although a deflection from our primary duty of care, we look forward to being part of a wider lean movement to serve the people of the Johannesburg area and beyond. We ourselves have much to learn. The lean journey, thus far, has been one of rich and satisfying learning. We look forward to further learning, and sharing the lean “way” with others.

_{THE AUTHOR}