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Healthcare is full of people trying to find things.
In our busy, dynamic work environment people and equipment are constantly moving around
the work area.
As a result, we know that this can lead to work areas becoming cluttered, untidy and
even unsafe.
Stock can be hard to find, or it could be out of date.
When staff can’t find the things they need they end up keeping more than they need of
something “just in case”. This is called hoarding or stashing.
Sometimes not all staff in an area know about a stash and so they think the area has run
out of something and order more, when actually there is plenty, just not where they were
looking for it.
Also, whilst the practice of hoarding or stashing may help one area to have what they need,
it means other areas may not have enough and leads to big variation in how much stock each
area has.
This variation makes it hard for stores people to know how much stock they need to order,
as they don’t know how much is actually in the ward and unit areas.
We tracked how staff spent their day and we know that nurses spend around 10% of their
shift doing non-productive activities such as looking for things or waiting.
Of that non-productive time, 70% of it was staff just looking for things.
Over a day this equates to up to 2 and a half hours per nurse spent looking for things.
Over a year, that really adds up.
Similar results were found when this type of research was done in overseas hospitals,
so it is not just a problem at our hospital.
Looking for things is not only frustrating and stressful for staff, but can also have
significant impact on patient care as patients don’t get the things they need when they
need them.
In order to improve the provision of care for our patients and create a less frustrating
work environment for staff, a process called 5S has been implemented in a number of wards
and units across the hospital.
5S is simply a system of 5 steps all starting with the letter S. SORT, SHINE, SET IN ORDER,
STANDARDISE and SUSTAIN
Before you get started it’s a good idea to take some photos of the area you plan to
5S.
Also, review data on the usage of items fro your cost centre over the past 6 months or
so, to get a feel for which items and how much of them you are currently using. Look
for patterns of use – are there any seasonal variations to factor in?
You may also want to ask staff what issues they are experiencing with stock, by questionnaire
or at staff meetings.
You need to let your manager, stores staff and other stakeholders know that you are planning
a 5S event.
SORT is about the process of understanding what is needed in a work area and what isn’t.
It is often helpful to make three piles: often used, sometimes used and rarely used.
You might need a quarantine area to keep some things if staff need time to decide whether
to keep them or not.
Find out ahead of time what stock stores will take back, or can be used elsewhere, if you
don’t need it anymore.
If unnecessary items are still in unopened boxes or bags, you may be able to return them
to stores and ask for your cost centre to be reimbursed.
If a work area is used by lots of different staff groups then it may be helpful to do
a red tag exercise.
This is where red tags are placed on items that are rarely used, or perhaps untidy or
disorganised or in the wrong place. Any staff can put a red tag on something.
These tags are left up for a while so that everyone can see which items may be removed.
That way other staff have a chance to respond to the tag and stop it being removed if they
believe that item is still used or needs to stay.
Red tags can also allow staff to realise that they are the only one who use a particular
item and maybe they could do what others are doing instead.
You are not allowed to red tag people. (unfortunately)
Once you have completed the SORT step the next step is SHINE. SHINE is simply about
cleaning the work environment, removing hazards and preparing to set up the work area, the
way it needs to be.
The next step is SET IN ORDER. This step is about setting up the work environment in a
way that promotes the flow of work.
It is often helpful to observe how people use the work area and identify the sequence
of how the work is done. What are the tasks you do a lot of? Are all
of the items you need to do those tasks stored together?
When we tracked nurses we noticed staff were leaving a patient bay up to 13 times to get
the things they needed.
The main items nurses left the bay for were then put in the cupboards closest to the patient
care area, to cut down on travel time.
Where are your storage areas? Plan for your most frequently used items to
be grouped together and if possible, close to point of use.
It is also helpful to think about which items are used for similar things, we call these
product families.
When organising items back into the area, think about what items are used the most and
put these in easier to reach places (between knee and shoulder height). Remember OH&S principles
of not having items on top of shelves or heavy items up too high or down too low.
You may need to check with infection control about appropriate storage, too.
Think about how much stock you have: do you know how much you use? Are the levels right?
Do you need more or less? Note these down, so later you can request stores staff adjust
the levels.
Having each shelf and compactus labelled enables you to develop an address book so it is easy
to find exactly where things are.
New or relieving staff often find the address book a terrific resource and time saver. They
also don’t have to interrupt other staff if they can find it themselves.
The fourth step is STANDARDISE, which is about making areas with the same function look the
same.
Lots of staff move around to different areas of the hospital, so having things set up in
a standard way with the same colours, labels and codes, means that it should be easy to
find the things you need, wherever you are in the hospital.
SUSTAIN is the final step of 5S and it is about maintaining the work area. Ideally 5-10
minutes a day should be all that is needed to keep the work area in its original condition.
Some work areas allocate 5S tasks to staff at double staff time
Sustaining happens best when maintaining the work area is linked clearly to roles and responsibilities,
and a manager checks at least occasionally that staff are maintaining the area in the
agreed way.
Showing or giving staff instructions on how to maintain the work area is also a good idea.
Since 2010 a hospital wide program has been assisting staff to implement the 5S principles
to each inpatient ward area.
This process has attempted to standardise each part of the replenishment cycle, from
using the item to provide patient care, through to replenishment of the item back on the shelf.
Each of the steps needs to be done correctly for the whole ward replenishment process to
work properly.
Each step has roles and responsibilities linked to it. This is really important for sustainability
and accountability.
The first step is use of stock for patient care, because the goal is to make sure staff
have what they need, when they need it, in an easy way, to provide patient care.
The next step is called “pre scan preparation” which is critical for ward staff to do so
it is easy for the scanners to see what needs to be ordered. Remember, for imprest items,
if it doesn’t get scanned, it won’t get ordered.
The next three steps are scanning the barcode, which is when the scanner indicates which
items and how much needs to be ordered. Picking, which is done based on what was scanned and
is available. And replenishing, which is putting the items back on the shelves in the wards.
The last three steps are the responsibility of stores staff. We all need to do our part
regularly and thoroughly for the replenishment cycle to work best.
An example of how to do a step thoroughly is the step in the replenishment cycle called
the pre-scan preparation process.
This is where wards prepare their store rooms ready for the scanner, by removing empty boxes,
ensuring bar codes are all there and in the right place. This is so that when scanners
come to scan items they can see more easily which items need to be scanned.
If you need to decant stock to other areas of the ward it is best to do this right before
your next scan day.
This works best when the pre scan preparation is incorporated into standard work practices
and is clearly allocated.
We have also found setting up a ward replenishment visual control board to be extremely useful.
The ward replenishment visual control board is set up based on the two questions staff
need to know to do their jobs “what do I need to know to do my job?” and “who do
I need to tell so others can do their job?”.
Ward staff need to know several things.
Who is the ward’s regular stores replenisher and how to contact him or her.
What day scan day is, and if the scan or replenishment has occurred.
So there are buttons next to the scanning day. Green means that step has occurred and
red means it has not occurred yet.
What stock is a shortage and not available in the hospital on their scanning day. There
is a clip for the shortages list to be put, so staff know where to find it.
Which items were scanned. There is a spot on the Ward Replenishment Visual Control Board
for the picking list to go.
The stores replenisher needs to know who to contact on the ward.
Which areas to scan on a ward, so there is a scan location map with the areas they need
to go to marked out on it. There is also a spot for ward and stores staff
to write notes to each other as needed.
Interview with Staff Member 1
Staff member 1: Before 5S we thought we were doing pretty well because we were a new unit
and had moved across in the previous two years. But after 5S we realised that things weren't
in the logical place.
There were quite a lot of instances where we found that we were critically low on stock
that nobody had seen beforehand. People spent a lot of time finding things, not putting
things back where they should so there wasn't a logical placement of all equipment.
But it would probably be the critical stocking that we either had too much of something that
we never used before or we didn't have enough of something that was critical to our core business.
Interview with Staff Member 2
Staff member 2: Well, our ward is very dynamic. It has four different areas - antenatal, postnatal,
gynaecology and gynae oncology so there is just a lot of stock for each of the things.
So as you add on, everything got put in different places so there was no central area for any
one thing so staff did spend a lot of time trying to find things on the ward.
Staff member 1: So, what we did is we had staff involvement and we asked staff to go
around and assess what they thought was important, what levels they thought we needed of stock.
We talked to them about the process. Jane, you came down and gave inservices to staff as well
so people were informed of the change that was coming. They were still a little bit unsure but they
had involvement, they had buy in and so when they saw those changes evolve because
of their commitment and input, there was more acceptance of the process I think. And yes,
some people said I'm not quite sure about that but overall the flow has been very good.
Staff member 2: The things that have worked the best for us I think is putting things into product
families so everything has their own area and they're in their own coloured boxed. Agency
staff, relieving staff, no matter where they work in the hospital, they know the coloured
boxes to go to, they know the area that it's in so it's easier to find things. It's in
one spot and that's what we like the most about it and if something new comes on to
the ward, you know where it's to go, what colour box it's to go in.
The visual control board is a bonus because we never knew when the storeman came, or he
hadn't been because he comes on a Friday for us so obviously at the end of the week it's
a little bit hard because you always run out of things. So when he comes, he puts it on
the board to say I've been, I've scanned the things so don't go rushing off to stores at
12 o'clock, I will be back which is great and then when he comes back he leaves us the
list of whats been picked, what we don't have in stock so we can look at that list by Friday
afternoon and if there's anything critical shortages for the weekend, we can source them
from other wards just for the weekend.
Staff member 1: It was a really seamless transition. We expected a lot more resistance to change
and there wasn't. I think because people could see how logical it was, it all made sense
to them. We've had fantastic signs and communication with the staff so they embraced the 5s'ing.
They could see that we were less on stock.
One of the key points as well was looking at where the pharmacy and stores people had
come along so there was less time of writing out of individual stock requests, phone calls.
We were much more efficient with our time and far less peaks and troughs of stock levels
so it's been fantastic.
Ultimately 5S is all about respect. All staff should be able to work in a safe and organised
environment and find the things they need, when they need them to deliver patient care.
(music and credits)