Toyota way in a state owned hospital

Lal Fonseka

Very recently I conducted a successful surveillance audit of ISO 9001:2008 in the Ampara General Hospital and within a space of another couple of months, this Hospital has emerged as the overall winner in the recently concluded National Productivity Award Competition. These two significant feats of the hospital prompted me to write this article.

According to the information available with them, this is not the first occasion where they have won an award of this calibre. Previously in many instances, this particular hospital has been able to achieve a number of awards locally and internationally. The details of those awards are listed below. There are altogether 12 awards. Ampara General Hospital is a state owned hospital and it is the only government hospital which has been certified for ISO 9001:2008 for its Quality Management System.

* 5 'S' Taiki Akimoto Merit award 2003

* Thaiki Akimoto 5 'S' Award - Winner (Service sector) First runner up (For all aver the competition) 2004

* Tahiki Akimoto 5 'S' Award 1st runner all over the competition 2004

* National productivity awards service sector 3rd place 2004

* Nagaki Yamamoto special KAIZEN award 2005

* Provincial productivity award winner 2005

* National productivity award winner (Service sector Large Scale) 2005

* National Quality award winner service sector 2006

* National productivity Gold award winner (Service & Manufacturing service sector) 2006

* International Asia Pacific quality award (Health Care) 2007

* National Productivity Award 2010/2011- Grade A

* National Green Award 2012- Silver

Undoubtedly this is a rare feat achieved by a government hospital and it is the outcome of the fantastic team-work this hospital has in their day to day work performance.

What is a hospital?

A hospital is an institution for health care providing patient treatment by specialized staff and equipment, and often but not always providing for longer-term patient stays. A hospital today is a centre for professional health care provided by physicians and nurses. The name comes from Latin hospes (host), which is also the root for the words hotel and hospitality.

As usual in any other organisations, even in hospitals unless they delight their customers who happened to be the patients (In-door or Out-door), clients of such hospitals will look out for alternative service providers. At the Ampara Hospital, since they always take every possible attempt to make their patients delight and happy, it has become a very popular hospital in the country. As per the hospital administration, almost every week they have got to entertain outside parties and organisations who come to see their achievements. Under these circumstances, winning quality awards of this nature cannot be treated as a miracle.

As per the well written management protocol of Ampara General Hospital, when a new patient arrives at the hospital, the triage nursing Officer will refer the patient either to the Out Patients Department (OPD) or the Primary Care Unit (PCU) on the condition of the patient. All admission to the hospital from 8pm to 7am will be done through PCU and 7am to 8pm admissions will only be done through OPD or triage referrals. All Critically ill patients are admitted through the PCU and on the findings of this unit; decisions are taken whether to give treatments in-ward or out-door to the patients. Ampara is a general hospital, which is set up to deal with any types of diseases and injuries, and typically has an emergency ward (PCU) to deal with immediate threats to health and the capacity to dispatch emergency medical services. A general hospital is typically the major health care facility in its region, with large numbers of beds for intensive care and long-term care, facilities for surgery and childbirth, bio assay laboratories, and so forth. Larger cities may have many different hospitals of varying sizes and facilities. But this is a wonderful hospital and it is worthwhile making a special trip to Ampara to see its ambiance and the quality service.

For decades, it has been a common belief that success in the marketplace was dependent upon organisations' ability to create satisfied customers. This was revealed in researches done by (Arnold et al., 2005; Parasuraman et al., 1985; Reichheld and Sasser, 1990; Rust and Zahorik, 1992, 1993). In fact, early scholars argued that the creation of a satisfied customer was the fundamental core of businesses or service centres (Drucker, 1973). Consistent with this argument is the fact that one of the central themes of the marketing concept is delivering products and services that satisfy customer needs. In return, satisfied customers are expected to exhibit behaviours that are favourable to the organisations, such as future patronage and making recommendations to others.

Because of the recognized importance of customer satisfaction, it has been a topic that has generated substantial attention among academicians.

Emphasis on customer satisfaction often stems from the thought that keeping current customers is much less expensive than attempting to attract new customers. Similarly in a hospital customers are the patients.

But another significant point that was noticed in Ampara Hospital is that they do not call these customers as patients. Instead, they call them as clients.

They are the people who come to the hospital seeking some redress or relief.

During my audit as was mentioned at the very beginning of this article, it was also observed that Ampara has adopted the world famous Toyota Production System successfully in carrying out their day to day functions. According to my knowledge, it is the only hospital in Sri Lanka which has adopted the Toyota Production System in a highly effective manner.

The Toyota Way is a set of principles and behaviors that underlie the Toyota Motor Corporation's managerial approach and production system. Toyota first summed up its philosophy, values and manufacturing ideals in 2001, calling it "The Toyota Way 2001." It consists of principles in two key areas: continuous improvement, and respect for people. As was told before, Ampara Hospital successfully applied the Toyota way in its hospital. The number of awards won by the hospital will be self-explanatory for implementation of Toyota way in the hospital.

The two focal points of the Toyota principles are continuous improvement and respect for people. The principles for a continuous improvement include establishing a long-term vision, working on challenges, continual innovation, and going to the source of the issue or problem. The principles relating to respect for people include ways of building respect and teamwork.

Research findings

In 2004, Dr. Jeffrey Liker, a professor of industrial engineering, published "The Toyota Way." In his book Liker calls the Toyota Way, "a system designed to provide the tools for people to continually improve their work." The system can be summarized in 14 principles.

According to Liker, the 14 principles of The Toyota Way are organized in four sections: (1) long-term philosophy, (2) the right process will produce the right results, (3) add value to the organization by developing your people, and (4) continuously solving root problems drives organizational learning.

Long-term philosophy

The first principle involves managing with a long-view rather than for short-term gain. It reflects a belief that people need purpose to find motivation and establish goals. In this aspect, Ampara Hospital administration has managed the hospital with a long-view especially on the followings.

1. The external environment: This includes such factors as performance monitoring and management; and the availability of cost-effective treatments and technologies including the beautiful surroundings.

2. Hospital management: This covers such factors as leadership and the use of effective management practices; cooperation between director and clinicians; and the speed at which new and cost-effective treatments and technologies are adopted

3. Hospital operational processes: These include the control of labour costs; the use of Nursing skill-mix by giving them adequate training; shortening length of stay in the hospital by patients; and measures intended to reduce errors and increase quality.

Right process will produce right results

The next seven principles are focused on process with an eye towards quality outcome. Following these principles, work processes are redesigned to eliminate waste (Muda- Japanese word for waste) through the process of continuous improvement - Kaizen. The seven types of muda are (1) overproduction/service; (2) waiting, time on hand; (3) unnecessary transport or conveyance; (4) over processing or incorrect processing; (5) excess inventory; (6) motion; and (7) defects.

The principles in this section empower employees in spite of the bureaucratic processes of State Sector, as any employee in the hospital system to take corrective and preventive action to extend an effective quality service emphasizing that quality takes precedence which is known as Jidoka in the Toyota Production system. Jidoka means in brief is automation with human touch. In another way we could describe it as autonomation which prevents the defective services, eliminates overprovision of services and focuses attention on understanding the problem and ensuring that it never recurs. It is a quality control process that applies the following four principles.

1. Detect the abnormality.
2. Stop doing excessive work
3. Fix or correct the immediate condition.
4. Investigate the root cause and install a countermeasure.

The way the Toyota bureaucratic system is implemented to allow for continuous improvement (kaizen) from the people affected by that system so that any employee may aid in the growth and improvement of the company.

Recognition of the value of employees is also part of the principle of measured production rate which is termed as Heijunka. On a production line, as in any process, fluctuations in performance increase waste. This is because equipment, workers, inventory and all other elements required for production must always be prepared for peak production. This is a cost of flexibility. Even in Ampara Hospital, fluctuations in performance is controlled through implementing decease preventive programs such as Combatting Malaria, Dengue and also having an isolated ward for infectious deceases such as TB and Chicken Fox etc.; this is known as demand amplification

These principles are also designed to ensure that only essential materials are employed (to avoid over services), that the work environment is maintained efficiently (5SProgram) to help people share work stations and to reduce time looking for needed tools, and that the technology used is reliable and thoroughly tested.

Value to organization

Human development is the focus of principles 9 through 11 in Toyota Way. Principle 9 emphasizes the need to ensure that leaders embrace and promote the corporate philosophy. This reflects, according to Liker, a belief that the principles have to be ingrained in employees to survive. Same thing applies in Ampara Hospital which is the very reason employees including the clinicians attached to the hospital wish to stay back in the hospital for longer periods. The present director has been working in the same hospital for last 10 years while the senior matron's service is more than 10 years.

I am told that even certain consultants do think twice before accepting the transfer orders. The 10th principle of Toyota way emphasizes the need of individuals and work teams to embrace the company's philosophy, with teams of 4-5 people who are judged in success by their team achievements, rather than their individual efforts.

In the Hospital, team-work is eminent very clearly through which hospital's philosophy is embraced by the various teams and departments of the hospital. Principle 11 looks to business partners, who are treated by Toyota much like they treat their employees. Toyota challenges them to do better and helps them to achieve it, providing cross functional teams to help suppliers discover and fix problems so that they can become a stronger, better supplier. This is another area Ampara Hospital is heavily concentrating and they too always try their level best to achieve the expectations of Ministry of Health and the Society and also to treat their suppliers to their maximum satisfaction. Solving root problems drives organisational learning

The final principles embrace a philosophy of problem solving that emphasizes through understanding, consensus based solutions swiftly implemented and continual reflection and improvement. Consensus decision-making is a group decision making process that seeks the consent of all participants. Consensus may be defined professionally as an acceptable resolution, one that can be supported, even if not the "favorite" of each individual. Here again in this hospital, Cross Functional Teams' meetings are frequently held and the Internal Quality Audits are being conducted at least once in every 6 months. Management Review Meetings are also held once in every six months and consensus based decisions are taken and implemented. This is a highly effective tool which the hospital does always use for their continual improvement.

The 12th principle sets out the expectation that managers will personally evaluate operations so that they have a firsthand understanding of situations and problems. This is sometimes referred to as "Get your boots on" and go out and see what is happening due to its similar cadence and meaning. It has also been compared to Peters and Waterman's idea of "Management by Wandering Around". This concept quickly became so universal that new managers instinctively knew that they had to "walk around" in order to achieve high effectiveness levels. Whilst these ideas, with their associated lists of how-tos, are probably good ideas they may miss the essential nature of Genchi Genbutsu which is less to 'visit' and more to 'know' by being there. Toyota has high levels of management presence on the production line whose role is to 'know' and to constantly improve. Similarly even in Ampara Hospital, all heads of the departments including the Director have a habit of making frequent visits in the entire hospital just to see what happens in the key areas such as Clinical Wards and Surgical Theaters. During these visits, actions where it is necessary are taken on the spot.

Principle 13 like in the Toyota Production System encourages thorough consideration of possible solutions through a consensus process, with rapid implementation of decisions once reached at Ampara Hospital. This is known as Nemawashi in Japanese Language. It means an informal process of quietly laying the foundation for some proposed change or project, by talking to the people concerned, gathering support and feedback, and so forth. It is considered an important element in any major change, before any formal steps are taken, and successful nemawashi enables changes to be carried out with the consent of all sides.

The final principle requires that Toyota be a "learning organization", continually reflecting on its practices and striving for improvement. According to Liker, the process of becoming a learning organization involves criticizing every aspect of what one does. There is no doubt about this principle as far as the Ampara Hospital is concerned as it is a learning organization. By looking at the awards they have won since year 2003 onwards, how can anyone say anything against it?

However, one of the strongest findings observed in Ampara Hospital was that good leadership, and effective general and clinical management which are both crucial for making productivity gains. I do now believe that after reading this article, you are now tempted to make a visit to the hospital as to see how they have successfully adopted the Toyota way in their operations.