The Corona pandemic is pushing healthcare systems around the world to their limits, and despite the heroic efforts of healthcare professionals, hard work is often not enough. Images coming out of the hardest-hit areas tell us of emergency departments filled to the brim, hospitals struggling to treat everyone because of the very high number of people the virus sends to the ICU, and exhausted staff often forced to work without adequate protective equipment.

As the Global Lean Healthcare Initiative, we support healthcare organizations around the world in applying 'Lean thinking and applying' in dealing with this crisis. Sharing our thinking across four continents, we have come up with seven key Lean applications. Each with a set of actionable tips that can really help a healthcare team more effectively address this emergency.

The seven Lean applications

1. Design the patient flow

2. Visual Management

3. Standard work to ensure safety, quality and efficiency

4. Commit to short, structured communication cycles

5. Build skills quickly with a people-development plan

6. Review of priorities to ensure capacity.

7. Level of staff capacity and protection.

1. Design the patient flow

• Understand the demand and pace of each patient flow.
• Visually map your newly designed flows and processes(Value Stream Mapping) to better understand and share them.
• Physically segregate streams and ensure that critical patients have access to specific resources so that they do not cross paths with other patients. Separate those with respiratory symptoms from those without symptoms. Minimizing the number of flow groups reduces complexity as we move patients through the system.
• Develop a plan for each flow: for example, Covid patients with mild symptoms and Covid patients with severe symptoms.
• Encourage "pull," by having downstream caregivers actively search for their next patients to move them to the right place as quickly as possible. Pulling patients from the ICU into an available bed allows the next patient to flow in. If possible, maintain some downstream capacity for outflow.
• Assign highly qualified professionals to intersections of Flow (flow) and to areas that make important decisions (such as Triage).

Example 1 - Argentina

In a Cordoba hospital, we converted the cardiac rehabilitation center into a special Covid-19 room to separate the flow of Coronavirus patients from that of normal patients. In this room (located in a separate building), we mapped the flow of patients, doctors, nurses, technicians, materials and information and made several improvements to reduce exposure and reduce the number of PPE per patient. We know that when the number of infections increases and serious or critical cases arrive, we will have to bring Covid-19 patients to the hospital. At that time, we will separate and isolate entire areas in three different stages to prevent any risk of further spread of infection.

Example 2 - Spain

This simple graphic maps the process followed for Covid-19 patients at a hospital in Catalonia.

Example 3 - United States

A health center in Massachusetts reorganized its workflows across several locations to reduce infection risk for staff and patients.

 2. Visual Management

• Share clear and visual work instructions for the critical steps in the process so everyone knows what to do and how.
• Place visualizations at each bed to minimize the time it takes to get the needed information. The goal is to create visualizations that deliver the needed information in seconds, at a glance.
• Use different color codes for areas, trails, classifications to make current standards clear, such as the purpose of an area, can change quickly and trails can be expanded or reduced at night. In this way, everyone is kept informed of the changing situation.
• Train professionals quickly using simple images.
• Incorporate visual management into your communications.

Example 1 - Australia

The team at the Australian hospital filled its "command center" and surrounding corridors with whiteboards to increase planning transparency. Now they can immediately see what is going on and what the team is doing, which has helped with connectivity and dependencies. They combine this with regular daily startups where they review key KPIs, progress against the visual Gantt chart, critical work-in-progress and addressing barriers. They visualize the work for today and assign help. Staff FAQs are also visualized, along with a status of supplies. All patient flows for COVID-19 are mapped and visualized. They are making changes in real time on the maps as they continue to develop their thinking about how these patients flow through the process flows and they can best care for them. Other teams regularly go to see what they are doing, to test the thinking and contribute. Connecting silos of frontline and leadership planning has been made both more effective and efficient by making things visible.

Example 2 - Argentina

At an Argentine hospital, visualizations, easy-to-understand instructions for donning PPE during Covid-19 testing are posted on the walls but also in the test kits - to make sure biochemists don't miss a step.

Example 3 - Spain

Checklist at each bedside to ensure professionals have all the information they need available in the workplace.

3. Standard work to ensure safety, quality and efficiency

• Develop standardized work and training teams in the use of these standards to ensure the safety and agility of your operations.
• Observe work and assess compliance with standards.
• Organize people (both management teams and care teams) into small integrated teams - physician, nurse, assistant physician, etc. - rather than large groups of professionals, to share vital information more quickly.
• Limit staff movement by organizing your space into dedicated areas for different teams.
• Enable leaders to identify priorities and necessary actions using Leader Standard Work. In a crisis, it is a good idea to create a central hub (incident command center) for information flow with visual management of key workflows(e.g., management of personal protective equipment; status of personnel -exposed and quarantined, tested positive, requests for replacements; etc). Leaders focus the teams with structured and frequent daily starts.

Example 1 - Australia

Executive leaders in the Australian hospital are daily at each site day start to show respect and communicate directly with staff.

Example 2 - Spain

These colored tags, in use at a Barcelona hospital, indicate different areas where healthcare professionals are deployed. When a doctor/nurse tests positive for Covid-19 and needs to go home for self-isolation, they place their tag in this plastic folder. This immediately tells the team who needs to be replaced. (As of March 30, more than 12,000 healthcare professionals in Spain have been infected with Coronavirus).

Example 3 - United States

A healthcare organization in Massachusetts organized itssenior leaders and managers into two parallel teams focused on two separate areas of the organization to reduce the likelihood of cross-contamination throughout the larger management team and preserve human capacity. This model was soon replicated with segmented healthcare teams.

Example 4 - Argentina

Cordoba Hospital's Crisis Committee has developed a set ofCovid-19 guidelines that can be accessed at any time through a URL code posted throughout the organization or through a link that health workers have installed on cell phones. These guidelines include definitions, protocols, flow charts, standard processes, etc. Most importantly, they are a "dynamic" document that is constantly updated as new evidence/information becomes available and as the team is called upon to address new challenges (especially important in this situation, as this is a new disease that we need to learn about quickly).

Example 5 - Brazil

At a hospital near Sao Paulo, all the equipment needed to intubate Covid-19 patients is organized into a ready-to-use standard kit.

 4. Commit to short, structured communication cycles.

Implement a daily management system to structure periodic meetings, short in duration, at all levels of management as a way to prepare people for the specific situation of a shift or day. Keep these daily starts in each work flow. Day starts can be virtual if teams are separate.

Create visualizations(signs) to act proactively and preventively by visually anticipating important decisions in case of difficulties, which will change every day.

Encourage people to communicate problems, difficulties and opportunities for improvement at all times.

Enable better communication by always working as a team.

Example 1 - Australia

The daily management system used at this hospital has been critical in ensuring that frontline teams are talking to each other daily about their concerns. We increased the focus on the frontline to create more structure and collect concerns, feedback and critical information every day. The department's group is now split into two: the safety day start at the beginning of each shift (duration of 5 minutes) and the "day start" by the top-level leaders to close the information loop and respond to the concerns of team members. This creates a time for teams to reset and connect during these stressful workdays. Day starts have proven to be such an important part of communicating and supporting each other. The team needed to redesign day starts to keep staff safe and meet the social demands of remoteness using a combination of technology and visual signs on the floor to help us maintain the social aspects of the day start process.

Example 2 - Spain

The panel in use at the "command center" in a Catalan hospital, with different colors referring to different areas addressing the Covid-19 emergency. The panel is updated daily/weekly as the situation develops.

Example 3 - Spain

These symbols are used to visually identify Covid-19-positive patients and those awaiting test results. The asterisk indicates that the patient's family has been notified.

5. Build skills quickly with a people-development plan

• Plan how to get people on board quickly and train new-team members. As physicians who have left for extramural work or retired physicians return to the hospital, along with other specialty physicians or new medical school graduates, you need to ensure proper orientation and knowledge to enable them to be productive as soon as possible.
• Use visual standards to quickly train and conduct on-site assessments to evaluate attainment.
• Bring the right knowledge to professionals - no more and no less. Not everyone needs to know everything at once, to avoid information overload and make it clear what people need to focus on. At the same time, transparency is key and everyone needs to get the bottom of what is happening in the organization.
• Take the time to record the lessons learned each day in a structured way (i.e., through the day's starters). It can save you a tremendous amount of time tomorrow as you continue to improve and learn. Learning is one of the most precious things that happens in burning platform situations.
• Recognize the importance of every little improvement and understand that quick action combined with rapid course correction (while learning what works best, through rapid-cycle PDCA) is the way to success.

Example 1 - Argentina

Chinese research on the virus indicated fever and cough as the main symptoms of infection, but there have been several covid-19 cases in the U.S. and Argentina that showed different symptoms(such as headache, fatigue, diarrhea and less cough). The virus can express itself in different ways in different places, which is why it is important to record data. In a hospital in Argentina, the team uses iPads for each suspected Covid-19 patient (we have a 24-hour delay on PCR results) to record the symptoms in each exam room and then upload them on a simple document on Google Drive. This information (what symptoms, how long it took to appear, etc.)is updated in real time and we expect it to be incredibly useful for us to learn quickly.

Example 2 - Spain

Visualization to train the different teams on each of the phases and main operations for ventilation, and when to do them.

6. Review of priorities to ensure capacity.

• Cancel and reschedule all non-urgent appointment and election procedures. If applicable, some of these patients may be seen using telehealth.
• Keep most patients away from the ED and do triage and testing outside/outside.
• Send teams from other areas of the hospital to provide support to the most critical streams.
• Place younger professionals on the front lines for interaction with patients and older and at-risk patients in the back office and assign them to telephone patient health support.
• Estimate the expected number of non-Covid emergencies using historical data.

Example 1 - United States

In Massachusetts, a 160-bed hospital was converted into a dedicated Covid-19 hospital - the first hospital in the U.S. to further segment the patient population and prevent further dispersion in the patient and staff community within a hospital. This also keeps the city's EDs and hospitals operational with capacity for other acutely ill patients at lower risk of infection. They do triage and testing in a mobile tent outside in their parking lot. Other countries, such as South Korea and the United Kingdom, have set up drive-through testing centers.

Example 2 - United States

A hospital in Massachusetts has partnered with an outpatient health center to care for their non-Covid patients, ensuring that patient flows are orderly and clear.

Example 3 - Argentina

A hospital in Cordoba - which primarily cares for cardiovascular patients (more than half of the total number), a category at high risk of complications due to Covid-19 infection - has analyzed the monthly/seasonal demand in the ER for 2019 to understand what they can expect in the coming weeks nop the area of emergencies (strokes, infarctions, etc.). This helps them prepare for the Covid-19 emergency.

7. Level of staff capacity and protection.

• Give people time to recover. This is important to avoid staff burnout and the mistakes that often result. Limit work hours and create a smarter shift plan so that teams are able to "run the marathon."
• Assign tasks by balancing staff (good balance in teams in terms of age, empathy, energy, mental strength, knowledge...) and try to train staff in more than one area, as these multi-trained workers can be moved where they are needed (creating flexibility).
• Create a plan for managing different levels of capacity (for example, when you add new IC beds to your Covid-19 flow). As your demand increases, gradually devise new plans for how the machines/equipment/spaces will be used/moved each time. Allocating all resources from the start can result in their ineffective use; it can also make any potential error much more damaging. Conversely, a plan with several iterations allows you to integrate your lessons learned and improve your response.
• Calculate how much material you need for each flow, process and scenario.
• Don't be afraid to start from scratch - set up the space using workplace organization techniques such as 5S and 3P and create standards for each flow, process, scenario.
• Make sure materials are always available to professionals when they need them. It is important to limit the searching for things because in hospitals, people usually spend hours walking and searching for materials. Always have someone responsible for replenishment and make sure you get the most out of the material.

Example 1 - Argentina

For the first time since 1977, doctors at Cordoba Hospital are working no more than 12 hours and nurses no more than 8 hours. As of March 28, front-line staff - under 60 years old - have been divided into three groups: the first two groups work for five days (one from 8 a.m. to 8 p.m., and the second from 8 p.m. to 8 a.m.); then the night shift goes home and stays in quarantine for five days (in case Covid-19 symptoms occur) and the third group comes in. The day group moves to the night group, and so on. In addition, we have a plan for managing different levels of Covid-19 patient demand and have decided how the different areas (i.e. ICU) will be converted for Covid-19 care in three phases.

Example 2 - United States

An ICU nurse in Boston noted how much PPE sheand her fellow nurses had to use when entering and leaving ICU rooms to adjust or respond to IV pumps. She proposed, got approval and tested the process of moving all infusion pumps outside the rooms, at the door, to preserve the use of PPE and make it faster for nurses to do this part of their work. Of course, nurses would still put on the PPE and check on their patients and infusion site, but this way they can reduce the number of times they enter or leave a room (such as when the pump beeps).

Example 3 - Brazil

One hospital in our network created a three-level plan to prepare for the various phases of the Covid-19 crisis.

Example 4 - Argentina

After their first suspected Covid-19 case - admitted March 23 - was found to be negative, the Cordoba hospital realized that a large number of PPE had been used (unnecessarily) to isolate the patient from caregivers and decided to revise the process to minimize staff exposure and PPE use. They mapped all touch points for that first patient during the 24 hours waiting for results and merged or eliminated some - ranging from 23 touch points per patient every 24 hours to 7-9 touch points with two-patients in the clinical rooms. For their first confirmed Covid-19 case, admitted to the hospital on March 29, the team had 10 touch points with a 57% reduction in PPE use over 24 hours for three consecutive days. For ICU patients, the original design began with about 60 touchpoints per patient per 24 hours and is now expected to be about 20 touchpoints per 24 hours for seven Covid-19 ICU patients. This was achieved by employing highly skilled professionals in the relevant areas and by implementing a Kanban replacement system.

Lean in Covid-19 times

The Lean transformations we facilitate usually take years to complete, but they are achieved by taking immediate action, day by day, as conditions around us change. Indeed, Lean Thinking can produce big results very quickly - and that is exactly what healthcare organizations around the world need right now.

We hope this article will reach healthcare professionals around the world, especially those who have never heard of Lean Thinking as they prepare for an onslaught of Covid-19 cases. For those who are not yet familiar with Lean , we would like to say: some of these suggestions may be quite different from your normal way of doing things, but we ask that you give them a try. It may even take a bit of time to implement them (we know how precious time is right now), but we encourage you to see this as an investment in your ability to meet the upcoming challenges of Covid-19. We have decades of experience in transforming healthcare organizations and believe that these measures can go a long way in combating this threat.

Our collective goal right now is to "flatten the curve" - to slow the spread of Covid-19 so that we can even out the caseload for hospitals, enable them to save more lives and have the time to get them the additional supplies and equipment they need. In Lean terms, this is clearly a global heijunka problem with far-reaching implications for our health care systems. The PPE debacle unfolding in many of our countries suggests that this crisis will also force us to rethink the way we manufacture and handle the logistics of key equipment. We think Lean Thinking has much to contribute to this debate as the world addresses this emergency and then begins to rethink life after the pandemic.

We wish you all strength during this difficult time!

Thanks to several Lean coaches from the Lean Global Network.