How to Ace Your Joint Commission Survey With Lean

An East-coast mid-size hospital passed its Joint Commission audit in December 2010 with flying colors. The lead surveyor had this to say in the exit interview: “So few finding from an organization your size is truly remarkable and unbelievable”. First consider the typical amount of work and stress during the weeks and months preceding a visit from the Joint Commission surveyors. Now think about a future where you are actually looking forward to the visit, and your chance to show off to the surveying team. This is a very attainable goal. Take care of your processes and the Joint Commission survey will take care of itself.

The best way to develop and sustain a process focus and a process improvement focus at your hospital is to embrace the Lean philosophy and principles. The Joint Commission itself has adopted Lean as its own process improvement methodology. For example, see the article “Don’t Just Talk the Talk: The Joint Commission tackles its own processes with Lean and Six Sigma, Quality Progress, July 2009” on the Joint Commission website.

Following are the five critical areas identified by the Joint Commission comments in their survey, along with some recommendations from the principal Lean consultant assigned to this hospital.

Recommendation 1: Launch a Strong Visual Workplace and 7S Program

7S is a formal approach to organization and housekeeping, and is a cornerstone of the Lean approach. The surveyors were very vocal about the hospital’s 7S program. They openly commented that this was one of the better organized work environments they had seen in awhile. To achieve this requires discipline and vision from the leadership ranks. At this particular hospital, the CEO made one departmental 7S project, plus a well-organized office, part of the annual appraisal for all the hospital leadership.

You must also focus on more than just the traditional 5S program that most books write about. This hospital embraced 7S, to include Safety and Security for every project.

Here’s how to ace your survey in this category. Train at least one or two 7S Mentors per department and unit. These individuals are not supposed to do all the work, but to be available to staff members as they embark on 7S projects.

Divide the hospital floor plan into a grid and assign an area to each executive to round for 7S status. Make sure that each executive is aware of the projects that have been completed, so they can poke their heads into the areas and give them a cursory check. Note to the executives: If you walk past a messy area and you say nothing, you are condoning the behavior. If you really want to make a difference, put on scrubs, roll up your sleeves and help 7S the mess. Now you have the moral standing to point out the mess and to demand its rectification.

Recommendation 2: Implement Tight Supplies Management with Kanban

The Administrator of Perioperative Services had her chance to shine by explaining the new and much more efficient supplies replenishment technique adopted by the hospital, the Kanban system. This hospital adopted Kanban as the methodology to replace the PAR system. The PAR level system is a bankrupt methodology that you must abandon as soon as you finish reading this article. The surveyors were also impressed by the organization of the supplies, driven by the Kanban management.

Here’s how to ace your survey in this category. This is a simple one, just implement the Kanban replenishment system for all your supply points. This is one of those issues that you will have to fight with your Materials Management department. Demand that they replenish supplies to your unit using Kanban. You may think that as long as the supplies are there you should not care how they get there. Stop and ask staff how often they have to call materials management, screaming for supplies that should be there. Next ask yourself how rational it is to count every supply every day, which of course, nobody does.

If you cannot get your materials management team to step into the 20th century, do a small pilot project with supplies that are not under their control. Then show the results and try again until they see the light.

Recommendation 3: Achieve a High Level of Staff Engagement

One of the seemingly “trick” questions to the Director of Process Excellence was “and who does the actual project and implementation of all these Kaizens documented by your department?” Their eyes lit up when the answer came back “well staff of course. RNs, Techs, and all the appropriate stakeholders.”

Successful Lean enterprises are not about “the few selected ones” but rather about a culture of continuous improvement that involves everybody. An engaged staff is the trademark of a mature Lean enterprise that will see long term sustainability of its efforts.

Here’s how to ace your survey in this category. Train everybody, and relentlessly remind every staff member of the importance of continuous improvement. Some hospitals hear about Lean and want to rush out to hire some engineers to create their own “Process Excellence” department. We encourage you to NOT do this. Do not even think about starting a “Lean Empire”.

Set up a department to manage and coordinate the training and the projects from each department and unit. This department should not do the projects, as they should be done by staff members in the units that identified the opportunity for improvement.

Recommendation 4: Understand and Deploy a Lean Management System

The Joint Commission surveyors were very keen on tracking the results of Lean projects with the same metrics the hospital uses to track their performance, rather than creating new ones. It is very important that the fruits of your Lean labors are reflected on metrics like patient discharge performance, patient satisfaction, physician satisfaction, staff satisfaction. This does not mean you should not track other metrics like patient room changeover, shortages per day, and OR Suite changeover but these must lead to improved overall hospital performance.

Here’s how to ace your survey in this category. If you have not done so already, tie your Lean efforts to metrics in the existing dashboards. Every hospital we know has a management dashboard. We encourage you to not create a new one. Keep the dashboard up-to-date and have a methodology to address deviations.

Implement local dashboards and use their physical location to conduct a daily 15-minute accountability meeting with the department’s management. These local dashboards may or may not have the same metrics as the rolled-up management dashboard.

Implement leader standard work. The closer you are to the delivery of value, the more standardized your work is bound to be. If you are a member of the management team, it does not mean that you have no standard work. One example is an end-of-day checklist for the SPD Manager to check the status of the department every day before going home.

Recommendation 5: Insist on Management Commitment

How do you expect a member of hospital leadership to understand and commit to your hospital’s Lean initiative if they do not understand the principles and the tools? They won’t. The best case scenario is that some will do their own research by reading some books (or maybe Wikipedia), while the most likely scenario is that the majority will pay lip service and balk at any request for resources to complete projects and sustain process improvements.

Here’s how to ace your survey in this category. Every member of the leadership team must attend a training session in which they get a chance to learn the principles and the tools and to practice them on live projects of their own.

Structure this training session as follows:

Day 1 AM: Lecture: Lean basics and Kaizen. Form teams and identify 5 opportunities per team. One of these will be the PM project.

Day 1 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 2 AM: All teams report on prior day’s projects. Lecture: Kanban and 7S. Select PM project on Kanban and/or 7S.

Day 2 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 3 AM: All teams report on prior day’s projects. Lecture: Standard Work. Select PM project on Standard Work.

Day 3 PM: Each team completes a project and prepares a 10-minute presentation for the next morning.

Day 4 AM: All teams report on prior day’s projects. Lecture: Value Stream Mapping (VSM). The class stays together and selects an area to map.

Day 4 PM: The class completes a VSM of the selected area.

Day 5 AM: Finish VSM planning by adding all the opportunities identified during the mapping exercise in a continuous improvement database. Close the morning by developing a plan for the Value Stream using simple Goal Deployment (Hoshin Kanri) tools like the A3-T Team Charter and the A3-X Chart.

Day 5 PM: Group presentation and celebration.

The comments, stories, suggestions above do not intend to be an all-encompassing set of solutions. They are mainly some lessons learned during a very successful Joint Commission Survey and the work in the months that preceded that survey. As you consider adapting Lean as your process improvement methodology, there are many other tools that are as important as the ones mentioned here. These other tools were also adopted by this hospital.

Now, it is your turn to take action. The Joint Commission survey does not have to be a stressful event. The surveyors are looking for solid processes. Focus on your processes with a Lean perspective, and you may even look forward to your next survey.