Lean-ing Toward Greater Efficiency in Daily Practice

00;00;01;05 - 00;00;41;26
Tom Haederle
The U.S. health care system has plenty of critics. But to one European-trained physical therapist, wastefulness and inefficiency were much worse where she came from. Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this episode, physical therapist Clare Fox with North Country Healthcare in New Hampshire, shares with the AHA’s Elisa Arespacochaga why she left her native England to pursue her health career dreams in the U.S., and how adapting LEAN training has made all the difference.

00;00;41;28 - 00;00;49;07
Tom Haederle
This series was recorded at the AHA's 2023 Rural Conference in San Antonio.

00;00;49;09 - 00;01;00;13
Elisa Arespacochaga
Good morning. This is a Elisa Arespacochaga at the American Hospital Association, and I'm here this morning with Claire Fox, director of performance improvement at North Country Health Care. Clare, welcome.

00;01;00;20 - 00;01;02;23
Clare Fox
Thank you very much. It's very nice to be here.

00;01;02;25 - 00;01;07;18
Elisa Arespacochaga
Well, that sounds like a little bit of an English accent, I hear. Clare, how did you get into health care?

00;01;07;21 - 00;01;27;15
Clare Fox
I think I was always destined to go into health care. At three years old, my mom was quite sick with Crohn's disease, so I decided I wanted to become a nurse. At six years old, I was a tomboy, so I decided I wanted to become a doctor because there weren't many females in medicine at that time. And 11 years old, I was a runner and I sprained my ankle and I got introduced to PT

00;01;27;15 - 00;01;50;19
Clare Fox
and from then on goal-oriented, I'd found my profession. So I was lucky enough to go to physical therapy school in England. And when I graduated in the early 1990s, I was honestly devastated with what health care was really like. I think I'd had health care on a pedestal for all these years, and when you get into it and you find out what the reality is, it was awful.

00;01;50;22 - 00;02;07;09
Clare Fox
I think I would honestly say that I was burnt out in my early twenties of of health care. And so at the time, 50% of jobs were vacant in this country. And so recruiters used to come over to Europe and said, hey, we'll double your wage...pay for you to get there, pay for three months rent. You just have to sign on the dotted line for a year.

00;02;07;11 - 00;02;11;00
Clare Fox
So that's how I ended up in Berlin, New Hampshire is where I landed.

00;02;11;05 - 00;02;29;21
Elisa Arespacochaga
That's awesome. And it's an awesome story. So as you came here, you're already thinking, I don't know if I can keep doing this. I've just come into a situation where so many jobs are vacant. How did you think about how to do the work? And you mentioned to me earlier that you were introduced to LEAN as part of this this journey across the ocean

00;02;29;22 - 00;02;33;26
Elisa Arespacochaga
among other things. How did that help you think about your own work?

00;02;33;29 - 00;02;53;02
Clare Fox
So I think I mean, I came from socialized medicine. And so at that time in the early nineties, there were a lot of waiting lists. I mean, if you had an acute injury, you'd wait two weeks to get into PT. If it was chronic, we'd see you in 3 to 6 months. If you needed a total knee joint, you'd get put on the waiting list and you'd be there for two or three years.

00;02;53;02 - 00;03;11;14
Clare Fox
People would literally die on the waiting lists. And so I knew that when I came over to the States, I'd be introduced to a completely different health care system. And whilst I don't really believe you should profit from health care, hence I worked at a non-for-profit.  I knew I had to experience something different. And so I was introduced to Lean.

00;03;11;14 - 00;03;45;19
Clare Fox
In about 2017 I met a gentleman called Dan Fleming from GBMP, and after he introduced me to...after I left that course that day, I was like, this is it! I really felt as though that this was my destiny. You know, they talk about the eight wastes in health care and I'll just mention briefly, and we do these very well in health care but inventory: too much of it. Motion: I can't find. Movements of information and materials. Overproduction. Over processing errors.

00;03;45;19 - 00;04;04;13
Clare Fox
We make errors in health care. Waiting - we have real estate dedicated to that. And under-utilization of people. And I think that's one of my biggest concerns is, is that so many people today that they they start their day and they're literally like, okay, where's the fire today? We've got one smoldering over there. We've got smoke over there.

00;04;04;19 - 00;04;25;06
Clare Fox
Fire. Oh, inferno. I'm going over to their first. And they're doing so many wasteful things. Unfortunately, they just can't really sort out the value from the non value added. And so I think that's why for me I'm like I think this is the only way we can save ourselves and our patients is to really help make health care a lot more efficient.

00;04;25;12 - 00;04;50;13
Elisa Arespacochaga
I love that you've tied this to your work around wellness in burnout, not just improving the performance of the organization and the efficiency, but the benefit it brings to your team in terms of their own wellness. So tell me a little bit about how you've been thinking about that linkage between performance improvement, wellbeing of your team and then that piece of that ties it together of the efficiency of practice. 

00;04;50;15 - 00;05;09;05
Clare Fox
Right. Like I said, a lot of people are stressed in health care and we do a lot of things that aren't very efficient. But I think one of the most one of the most important things is that people who do the work know the work best. And so I don't feel as though sometimes that their opinions are always respected or heard.

00;05;09;07 - 00;05;43;07
Clare Fox
And I think when they are not, that that leads to a lot of demoralization and hence burnout. And so I think that that's what LEAN for me offers, it offers us to be able to go to the place where the work is done and say, "Hey, guys, you're the experts." You know, let's use data and measure things and then looks really, truly understand the problem, figure out how we can how we can fix it, and then look at the comparative data before and afterwards and help to take out the variation and then get less errors, but also help to save ourselves.

00;05;43;10 - 00;06;07;24
Elisa Arespacochaga
Absolutely. So you mentioned a little bit about really going to the place where the work is being done, and that really feeds into the culture of the organization. Right. That front line bringing elevating that work at the front line to the entire team and understanding how it is that the culture of the organization impacts both the performance and the well-being of the team.

00;06;07;24 - 00;06;13;01
Elisa Arespacochaga
Can you tell us a little bit about how you're engaging with the culture? Because that's everybody in the organization.

00;06;13;01 - 00;06;35;02
Clare Fox
Sure. We had a new president in the mid 20 teams called Mike Petersen, and one of the first things he did at NCH was he spent a long time building culture and so he had teams and and they were build they were writing booklets and throwing out, you know, words of sense of ownership, collaboration, quality, integrity, flexibility, communication, service and accountability.

00;06;35;08 - 00;07;00;08
Clare Fox
And I'll be honest with you, I didn't really get it. I was like, oh, my goodness, let's just, you know, work on improving things, shall we? And then I stay. As I did more work on LEAN, I realized so much of it is built on the foundation of culture. Are we a facility who punishes when there's an error or are we a facility who says maybe it's not the people who will come to work to deliberately make a mistake?

00;07;00;14 - 00;07;16;09
Clare Fox
Maybe it's the processes. And so if you don't have that baseline culture, you can't improve things. I swear I could improve any anything in any industry. But if you don't have the culture to support it, it's only going to be like a flash in the pan.

00;07;16;11 - 00;07;21;25
Elisa Arespacochaga
Absolutely. So tell me a little bit about what you have done at NCH thus far.

00;07;21;27 - 00;07;45;07
Clare Fox
Sure. So we've built our wellbeing program under under three pillars work, general wellbeing, culture and also efficiency. And some of the things that we've done within NCH: we initially focused a lot on the providers, but now we're we're trying to grow it to everybody and I mean everybody, not just clinical staff. So we have a professional wellbeing team.

00;07;45;09 - 00;08;09;00
Clare Fox
We wrote a peer to peer support for providers. We've done one on one shadowing to try and see how we can make their work a little bit more efficient. Our AD director Dr. Moore got her certification in chief wellness officer and due to the way that behaviors of our patients have changed over the years and not always for the better, we've had to put posters around our facilities.

00;08;09;00 - 00;08;27;29
Clare Fox
We do not tolerate or, you know, please respect, which is kind of sad. But the other thing that we've done is, is we've committed committed to LEAN Six Sigma. And so by September of this year, 50% of our employees will have taken the class and 100% by September of next year. People can do a project if they choose to.

00;08;28;05 - 00;08;52;24
Clare Fox
But now we're all have it all speaking the same language. And we have change agents everywhere among our everywhere in our organization. We're going to have a thousand people who potentially are empowered to be able to make basic changes of their work area. You can't beat that. No. I mean, we have onsite clinical psychologist, we have music therapy, and this isn't across all sites.

00;08;52;24 - 00;09;04;20
Clare Fox
It's just some of the things that we've done. But it's certainly a long journey for us. And we know I think it feels like we're in mile one of a marathon and it's definitely very complicated, but we're certainly excited.

00;09;04;22 - 00;09;38;15
Elisa Arespacochaga
Yeah, and I know we talked earlier a little bit as we were getting ready for this, that health care is in a place where we're going to have to work smarter because we will not have more likely not have more people coming into health care to fill all of the positions that were there. So as a health care leader and someone who's focused on performance improvement and quality, what kind of advice do you have for those who want to really marry both the efficiency and the improvement, along with maintaining that well-being of your team?

00;09;38;15 - 00;09;42;29
Elisa Arespacochaga
Because you obviously need all three pieces to to work better and smarter.

00;09;43;02 - 00;10;07;21
Clare Fox
I love to use the old adage, just do it. But I'd say lead with humility. Respect your workers. Let's try and get out of our silos that we are so well at working in in health care. Collect the data before and afterwards. Make sure you truly understand the problem, Make the journey your own. And it's a long journey.

00;10;07;27 - 00;10;14;11
Clare Fox
But I think we owe this to ourselves and our patients to do it because we have to save ourselves here.

00;10;14;14 - 00;10;23;22
Elisa Arespacochaga
Absolutely. Claire, thank you so much for sharing your thoughts, your advice. And I'm looking forward to continuing to watch what you do at North Country Healthcare.

00;10;23;24 - 00;10;24;20
Clare Fox
Thank you very much.