Toyota work methods applied at General Hospital

S.F. General Hospital and Trauma Center rebuild project

San Francisco’s Department of Public Health has a $1.3 million contract with Seattle-based Rona Consulting Group to implement the Toyota Management System, a workflow methodology based on the auto-manufacturing model, at San Francisco General Hospital.

This new model, which aims for greater workflow efficiency, is being implemented just as healthcare staffers raise concerns that staffing levels at SFGH are dangerously low.

“Nurses often work through their breaks, and they stay after their shifts to get charting done,” said David Fleming, a registered nurse who has been at SFGH for 25 years. “I think nurses are getting the job done – but they’re at the edge.”

A group of healthcare workers spoke out at the May 7 Budget & Finance Committee meeting, during which supervisors discussed the DPH budget. Public employee union SEIU 1021, which represents healthcare workers, is in the midst of contract negotiations but Fleming said they had been grappling with reduced staffing for awhile.

According to a contract request to the Health Commission sent anonymously to the Bay Guardian, DPH entered into a 24-month contract with Rona totaling just over $1.3 million, for the purpose of implementing the Toyota Management System methodology as part of the transition to the new SFGH acute care facility, scheduled to open in December 2015.

The Bay Guardian received a copy of the contract request via BayLeaks, which uses encryption software known as SecureDrop to enable sources to anonymously submit documents.

The $1.3 million came from “General Funds (Rebuild Funds)”, according to the contract request. In 2008, voters approved Prop. A, funding the $887.4 million General Hospital rebuild through general obligation bonds. Use of the voter-approved, taxpayer-supported funds is restricted to hospital construction under a state law that limits the use of bond money to specified purposes.

However, Iman Nazeeri-Simmons, chief operating officer at DPH, said funding for the Rona contract came from a “hospital rebuild transition budget,” which she said provides for needs beyond construction costs.

Specialized consulting to educate hospital staff in the ways of the Toyota Management System doesn’t come cheap. A single meeting between the consultant and “key leaders” to “discuss needs and develop operational project plans” cost $25,225, the document showed. A one-day “visioning session” facilitated by the contractor was priced at $16,814. Five-day workshops fetch Rona $42,032 each. Based on estimates included in the contract request, the consulting firm would earn the equivalent of $4,707 per day.

The $1.3 million consulting contract was awarded even as unions remind city officials of staffing cuts during the economic downturn in 2008 that still have not been restored.

Here's some video testimony from hospital staffer Heather Bollinger regarding how tough things can get at the General Hospital's trauma center. "We do have staffing issues, and they do affect patient safety," she said in public comment to the Health Commission on April 15.

Nato Green, who is representing nurses as a negotiator on behalf of public employee union SEIU 1021, described the staffing levels at SFGH as “unsafe and unsustainable.” There are currently 90 vacancies for nurses that haven’t been filled, he said. That’s a 14 percent vacancy rate, Green noted -- typically substituted with traveling nurses, temps, and overtime labor.

Nazeeri-Simmons said the consulting was necessary for the transition to the new SFGH facility, for “doing it in the best way, and understanding there’s a completely different physical environment over there.” Rona is a pioneer in healthcare performance improvement, she said, and they are “leading us in very interactive workflow designs that are simulation-based,” geared toward “maximizing value and driving out waste.”

But does “driving out waste” translate to staffing cuts? “It certainly hasn’t happened here,” Nazeeri-Simmons responded when asked about that. Instead, the consultants have helped management to “right-size services to meet the demand,” she said, noting that wait times in urgent care had been significantly reduced as a result. Decisions such as using a portable X-Ray machine that eliminated the need for patients to walk ten minutes across the hospital grounds had dramatically reduced wait times, she added.

“We need to make sure the staff are working to the highest of their capability,” she added.

Heidi Gehris-Butenschoen, a spokesperson for Rona, said the goal of transforming work practices under the Toyota Management System is to improve patient care. Asked whether the consulting tends to affect staffing levels, Gehris-Butenschoen said, “That’s really up to the hospital. It’s definitely in our workshop not something we focus on. The Toyota system is not about cutting heads at all.”

SFGH has been working with Rona since July 2012. One of the company partners was formerly the CEO of Productivity, Inc., which advised “large-scale transformations for Fortune 100 companies,” according to the contract request. The workflow methodology is rooted in Lean principles, integrating a “just in time” staffing concept that’s been applied in corporate settings such as Walmart.

The Health Commission approved the $1.3 million contract at its Dec. 17, 2013 meeting as part of the consent calendar, which is summarily approved by a single vote.

Fleming, the RN, was skeptical of how much the Lean system had actually accomplished. They had literally “rearranged the furniture” since the program was implemented, he said, and observers had silently monitored staffers’ activities.

“When we work with anyone, we go out to the gemba, and we observe,” Rona’s Gehris-Butenschoen explained, noting that gemba refers to “the place where work happens.” The observations help hospitals identify where waste can be reduced, she added, such as moving a supply cabinet if time is being taken up by crossing the room to get to it.

But Fleming said he wasn’t convinced that applying a corporate efficiency method, borrowed from manufacturing, would provide the greatest benefit in a healthcare setting.

“We are not taking care of cars on an assembly line,” he said. “When it comes to another human being’s body, I don’t know that faster is necessarily better.”


Hospital workers should form a radical collective and apportion work by consensus!

Give me a break. What do progressives know about managing anything?

Posted by Angus T Jonesing on May. 07, 2014 @ 5:38 pm

Criminy, a new level of rediculousness!! So on one hand the SEIU is complaining that *patients* aren't getting the care they need. So the hospital brings in consultants to improve efficiencies, reduce wait times, etc. this helps patients, right? And the $1.3 million dollar cost is probably about 6-8 years' worth of a single nurse's salary and benefits. Even if they make no other improvements, the time saved by eliminating the 10-minute walk to the x-ray machine will more than pay for itself in that time in improvement to patient care and reduced labor costs.

When is the SEIU going to cut the charade that they are there for patients and customers and admit that it's all about salaries, union dues and political power. Unions like the SEIU have a vested interest in preserving inefficiencies in order to keep their cash drawer full and membership high.

Posted by Guest on May. 07, 2014 @ 8:03 pm

That is one thing all nurses want! More portable X-ray machines! Hallelujah we got more X-ray machines!

Posted by Florence Nightingale on May. 08, 2014 @ 9:39 am
Posted by Guest on May. 07, 2014 @ 8:48 pm

"“Nurses often work through their breaks, and they stay after their shifts to get charting done,” said David Fleming, a registered nurse who has been at SFGH for 25 years."

According to SF Gate's handy-dandy city government salary database, David Fleming got a base salary of $136,359 in 2012-13, plus about seven grand in overtime and other pay, for a grand total of $143,356.

Posted by Guest on May. 07, 2014 @ 10:02 pm
Posted by Guest on May. 07, 2014 @ 10:19 pm

It does help explain why SF General doesn't have the money to fill the vacant nursing positions...

Posted by Guest on May. 07, 2014 @ 10:29 pm

properly staffed,

And the less employees on the payroll, the more likely those insanely generous pension benefits can be preserved

Posted by Guest on May. 07, 2014 @ 10:52 pm

Let's take SEIU out of the equation. At the Health Commision and the Board of Supes hearings, RNs who are NOT union activists came forward as individuals to share their concerns about dangerous staffing levels. Why would they do this if they wanted to preserve the right to make the big bucks working OT? Dave Fleming working OT? Let me guess why. He works In the recovery room where patients get back logged because there are no ICU beds available to which to transfer them. Patients coming out of the OR needing 1:1 or 1:2 ICU care spend many extra hours in the recovery room. I have no doubt that there were days Dave wanted to go home, but the situation was not safe for the oncoming patients. Nurses are NOT complaining about our salaries. We know we are paid well for hard work. We are trying to warn the powers that be and the community that things are getting dangerous for patients and staff. RNs lose sleep over whether we missed something or inadvertently harmed a patient. And on some shifts, we are at risk of being assaulted. Some if us don't finish our careers w/o neck and back injuries, losing eyesight from an assault, or becoming Hep C or HIV positive. We witness severe human suffering and the last thing we want to do is make that worse by accidentally harming someone due to short staffing. Don't kill the messengers.

Posted by Really? on May. 08, 2014 @ 12:25 pm

Complaints about dangerously low staffing levels have been made beginning two years ago in the ED. Various letters detailing ongoing unsafe work conditions were signed by the majority of ED RN staff. They went ignored. We have been escalating our concerns since then. These aren't new complaints.

Even when factoring in SFGH's comparatively generous pension and benefits to normalize wages, we are paid less than other SF nurses. Despite that discrepancy, when the union surveyed nurses about their priorities in this bargaining session, safety and staffing were the #1 concerns, not salary.

Posted by SFGH RN on May. 08, 2014 @ 2:52 pm

The Toyota system succeeds mostly as a means of generating ungodly paperwork and wasting a lot of time in meetings. It was the next big thing in the '80s.

Posted by Chromefields on May. 08, 2014 @ 6:23 am

it makes them feel like they have done something.

Posted by Guest on May. 08, 2014 @ 6:23 pm

Jason Grant Garza here ... would this be the same San Francisco General where I was denied EMERGENCY CARE on 4/30/14? and denied ADA rights such as my "Programmatic Access" under Title II for healthcare ? What is Programmatic Access per ADA Title !! ... from the Mayor's Office on Disability ... ... Why? ... not to mention years of seeking health care and being denied

So ways to create a better "assembly line" yet where is the HUMANITY, PROFESSIONALISM and MEDICAL OATH to do NO HARM? Keep Drinking the Kool-Aid.

Posted by Jason Grant Garza on May. 08, 2014 @ 7:54 am

However Jason, you're not a medical professional. So considering doing yourself in soon, before they put that barrier on the bridge. Or maybe something more creative - you can do it Jason!!

Posted by Guest on May. 08, 2014 @ 3:12 pm

Management paying $1.3 million dollars to help them manage the hospital. Managers paying people to manage the hospital for them? That is their job! $1.3 million dollars and the main talking point they can bring up is that we now use portable X-ray machines?!?! Hospitals have been doing this for years. Money well spent. You can hire consultants and experts to improve process, but without the adequate staffing to enact these changes, that is money down the drain.
The hospital has already doled out millions for "Hospital Improvement." INLP, TCAB, and half a dozen councils with what to show for? Portable X-RAYS!
It's like installing solar panels, brand new paint, andexpensive furniture in a house with a faulty foundation and structure.

Posted by Florence Nightingale on May. 08, 2014 @ 9:33 am

Let's be clear. This is the SFBG's story and LEAN is not a complaint that has been brought forward in nursing testimony over the last month. We are concerned about staff cuts that have impacted patient safety and helped precipitate some of the recent negative outcomes at SFGH.

It is unfortunate that we are being painted as anti-efficiency here. In general nothing makes a nurse happier than an efficient well functioning environment. It is the meaningless delays that make us want to pull our hair out. Waiting hours for beds that should be available, etc... For the record the LEAN program in Urgent Care has been generally welcomed by staff. Family Health Center nurses characterize themselves as "desperate" for efficiency. There is something of a false dichotomy that has been created here. Ideally nurses would be adequately staffed in an efficiently run environment.

Finally, vacancy rates are so high that there aren't enough travelers, part time, or full time nurses willing to pick up OT to fill all the spots. Sure there is some back fill, but the reality is that many areas are operating with far fewer staff than are needed.

Posted by SFGH RN on May. 08, 2014 @ 10:26 am

The real issue is that rather than address staffing and
safety issues, the hospital prefers to pay outside consultants
to address minimally significant issues. The real problem
is poor staffing on multiple levels.
But, Let's not address that issue. Let's see if
we can make the nurse harder and faster. Oh, and.
when we do our analysis, let's not have any discussion
about what is happening or what the issues may be,
Let's just make assumptions and move a few things

As for what nurses are paid at San Francisco General
Hospital, the pay scales are well below what other
Nurses are paid at other hospitals.

Posted by Guest on May. 08, 2014 @ 11:26 am

The real issue is that rather than address staffing and
safety issues, the hospital prefers to pay outside consultants
to address minimally significant issues. The real problem
is poor staffing on multiple levels.
But, Let's not address that issue. Let's see if
we can make the nurse harder and faster. Oh, and.
when we do our analysis, let's not have any discussion
about what is happening or what the issues may be,
Let's just make assumptions and move a few things

As for what nurses are paid at San Francisco General
Hospital, the pay scales are well below what other
Nurses are paid at other hospitals.

Finally, Urgent Care is not without significant issues.

Posted by Guest Nurse on May. 08, 2014 @ 11:27 am
Posted by Guest on May. 08, 2014 @ 12:06 pm

Are there no Lean consultants in SF? I would do the job for much less on a 2-year contract basis, and the first thing I would do is start the culture of 'nemawashi' or consensus building, without which any derivative of the Toyota system fails at anything except getting the top employees to leave. Second and third, recommend raising the minimum wage for the lowest rung, the cleaners, to $15 as in Seattle, and the sacking of the top layer of management. No Japanese company would put up with such inequality of pay and benefits. I'm from Seattle, summered on the shop floor for a Toyota subcontractor, and received my certification in these methods in SF. Most of these consultants are tossers with nice ties.

Posted by Guest Lean Consultant on May. 08, 2014 @ 1:31 pm

Would the Toyota system have saved Lynne Spalding's life?

Posted by Guest on May. 09, 2014 @ 8:07 pm

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