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Healthcare is ripe for lean

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This paper was published in Jan/Feb issue of Industrial Management. All rights reserved.

To cite this publication please use: Soliman, M.H.A (2018). Healthcare is Ripe for Lean. Industrial Management 60(1), 25-30. DOI: 10.6084/m9.figshare.9037805

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Healthcare is ripe for lean

  1. 1. january/february 2018 25 Healthcare is ripe for lean BY MOHAMMED HAMED AHMED SOLIMAN EXECUTIVE SUMMARY Trucks are not as important as patients, but through the Toyota Production System and lean principles, car manufacturers often put far more effort into supporting their front-line staff than many hospitals.This is a shame, because properly applied, lean tools like work standardization, 5S, visualization and kanban can deliver great results in the medical field.A hospital lean transformation can save money and, more importantly, lives.
  2. 2. 26 Industrial Management Replacing batch processing with one- piece flow can save thousands of dollars and dramatically reduce turnaround time. 95percentandsaving$1million.The UniversityofPennsylvaniaMedical Centerreducedhospital-acquiredinfec- tions,saving57lives,reducinghow longpatientsremainedinintensive careandcuttingcostsbymorethan$5 millionovertwoyears.ThedaCarein Wisconsinreducedpatientwaitingtime fornonemergentorthopedicsurgery from14weeksto31hours,improving itsinpatientsatisfactionscorefrom68 percentto90percent.PaloAltoMedical FoundationinCaliforniareduced waitingtimeforscreeningcolonoscopies fromsixweekstolessthan24hours whilereducingcostperpatientby9.5 percent. Labproductivitycanbeincreasedby improvingturnaroundtime,thetime fromwhenapatient’ssampleisdrawn untilheorshelearnstheresults.Poorlab layoutblockstheflowof samples.Many labsusebatchprocessing,whichkeeps sampleswaitingbeforeinspectionand diagnosis. Replacingbatchprocessingwith one-pieceflowcansavethousands ofdollarsanddramaticallyreduce turnaroundtime.Graban’sLeanHospitals citedacasewheremovingthespecimen collectionpointinthelabclosertothe diagnosticdeviceslashedlaboratory turnaroundtimeby29percent. Speedierturnaroundtimealso benefitssurgicalcenters.Manyhospitals prepareforthenextsurgeryinthe downtimebetweenprocedures.Applying theToyotaProductionSystem’stool knownassingleminuteexchangeof die(SMED)preparesthenextroom forsurgerywhilethecurrentoneis inprocess,gatheringallthetoolsand instrumentsintotheirproperplaces. Thisreducesexpensivedowntime. Theseachievementsprovethat applyingleaninhealthcarecandeliver resultsintermsofpatientsafetyandcare, allwhilereducingcosts. It’s all about the waste Theeighttypesof waste(thetraditional seven–time,inventory,movement, waiting,overproduction,overprocessing anddefects–pluswastedtalent)provide manyopportunitiesforimprovementin healthcare. Inmedicalcare,anyprocessthat doesn’tprovidepatientcareshouldbe considerednonvalue-added.Examples includedoctorswhostandinthe diagnosisroomwaitingforsomeone tobringamissinginstrument,rework causedbydefects(bringingthewrong drugorincorrectdosage,whichcanharm patients),storingdrugsforadultsinthe newbornintensivecareunitandfailed blooddrawsthatneedtoberedone. Underutilizationofhumantalent canincludealaboratoryphysicianwho drawsspecimensorloadsthemonthe diagnosticdevice.Youngassistants candothosejobswhilethephysician analyzesandtroubleshootsthetest results. Nursesshouldspendtheirtime chartingwithpatients,discussingtheir healthwiththem,describingproperdrug dosageandadministrationandother in-patientcareissues.Unfortunately, manynurseswastealotoftimewalking betweendepartments,searchingfortools andbringingpatientsdrugs.Someof theseactivitiescanbedonebypeople withlessexpertisetosavemoneyand allownursesmoretimewithpatients. Onesimpleprocessimprovement involvesbags–yes,bags.Insome hospitals,nursescarrymanyoftheir toolsandinstrumentsinawaistbag, whichsavesthemfromwalkinghereand theretofindthenecessaryitems. Suchanimprovementalsohelps reducewaiting,themostcommonwaste inallhospitals.Thewasteof waitingis acutelyobvioustopatientswhowaitto makeanappointment,waitwhenthey arriveattheoffice,waittopaybillsand waittogetdischarged.Doctorsoften waitforthetoolstheyneed.Otherswait forpharmacyorders,medicationsand toolsthatareproperlysterilized.Allof thisdelayspatientcare. Hospitallayoutgreatlyaffectstrans- portationwaste.Anurseonanintensive careunitmightaveragewalkingfrom7 to9kilometersperday.Properlayouts minimizethis,alongwithreducing transportationtimeforpatients, Leanthinkingisasetofconcepts,strat- egies,principlesandtoolsthatcandeliver themostvalueforcustomerswhile consumingthefewestresourcesandfully usingtheknowledgeandskillsofthe workforce.AsdefinedbyMarkGraban, authorofLeanHospitals:ImprovingQuality, PatientSafetyandEmployeeEngagement,lean healthcaremeansdeliveringthemost valuetopatientswhileconsumingthe leastresourcesandmaximizingtheuse ofpeopleskillsandknowledge.Lean healthcarestrivestoimprovequality, preventerrorsandmakepatientssafer, allwhileremovingwastesandthepossi- bilityofdefects. Afterall,defectsinhealthcarecanbe catastrophic,threatenlivesanddirectly affectpatientsafety.Defectsormistakes canleadtoimpropersterilization, dispensingthewrongdrugstothe wrongpatient,incorrectdrugdosagesor improperdiagnosis–allof whichcanbe hazardoustoyourpatients’health. Proof from the front lines Leancanapplythroughoutamedical system:Opportunitiesforimprovements canbefoundinlaboratories,clinics, diagnosisrooms,operatingrooms, surgicalroomsandintensivecareunits. Beforelean,“improvement”meant doingworkfaster.Butacceleratingwork doesn’tnecessarilymakethingsbetter and,infact,candecreasequality.Making peopleworkfastercanoverburdenthem, leadingtoanunbalancedworkloadthat cantriggermoremistakes,errorsand createwastesinotherlinkedareas. Lean,ontheotherhand,worksby takingoutwastesandthenon-value- addedstepstoimprovevalue-added processes.Therefore,leanhealthcareis notaboutcuttingcostsbyreducingthe levelofserviceandthequalityofcare. Instead,leanhealthcareputsmorevalue inpatientcare.Improvingqualityisthe keytosavingcosts. Grabanhighlightedsomeexcellent achievementsinLeanHospitals. Forexample,AlleghenyHospitalin Pennsylvaniareducedcentrallineblood- streaminfectionsby76percent,reducing patientdeathsfromtheseproblemsby
  3. 3. january/february 2018 27 Overprocessing is replete in medical care, particularly with patients who have to describe their symptoms multiple times. butonthesametrip.Anotherexample involveslabsthatusemoreofthehypo- osmoticswellingsolutionwhenevalu- atingthespermmembranetoassess spermvitality.Theextrausedoesn’tmake adifferenceandisjustwaste.Andsome labsleavesperminthesolutionlonger thannecessary,whilelessthanaminute ismorethansufficient. InherbookValueStreamMappingfor HealthCareMadeEasy,CindyJimmerson showedhowmappingtheprocess cantacklewastesinpatienttreatment processes.Theprocessofpatient treatmentstartswhenthepatient feelssymptoms,continueswiththe patientreceivingcareandendswith billpayment.Theprocessmayinclude makingappointmentstomeetdoctors, screeningsandanalysis,deliveringtest resultsandreceivingtreatment,along withfollow-upsuntilfullcure. Standardization is the foundation Standardizedworkisafoundation ofleanandisakeyforgoodquality. Withoutstandardization,allof your nurses,technicians,physiciansand administrativestaffwillperformtasks differently.Thismakestrackingthe sourceoferrorsdifficult.Without standardization,thetraditionalgemba walk–leadersexaminingwherethe workisdoneandanalyzingprocesses– ispointless. Thestandardshouldinvolvethework elements,theworksequence,thetools, equipmentandmaterialneededandthe amountoftimeitshouldtake.Without thoseelements,workerswillhavenoway ofknowingwhethertheyhaveimproved. Doingthejobdifferentlyeverytime makesconsistentqualityandproduc- tivityimpossible. Alackof standardsinprocessescan leadtomiserableresults.CBCNews reportedonNorthernHealth,ahospital inEngland,thatperformedprocedures on10,000patientsoverthreeyearswith improperlycleanedendoscopes. specimensandotherhospitalstaff. Wastedmotion,whichcanreferto workplaceergonomics,alsoappliesin hospitals.Iftoolsandinstrumentsaren’t handy,peoplewillmovehereandthere searchingforthem. Medicaloverproductionusually involvesunnecessarytestsandcheckups. Overproducinginformationthatisnot usefulorwon’tbeusedisawastethat candelaytreatmentandaddcosts. Hospitalsalsofacethetraditional trade-offbetweenkeepinglimited inventorywithoutrunningoutof necessarysupplies.Leanencourages havingtherightsuppliesandinventory onhandtoensuretherightpatientcare canbedeliveredontime.Aleantoollike kanbancanensuretherightsuppliesare availableintherightplaceattheright time. Overprocessingisrepleteinmedical care,particularlywithpatientswhohave todescribetheirsymptomsmultiple times–notjustinfollow-upvisits,
  4. 4. 28 Industrial Management Waste … will delay patient discharge and keep rooms from opening up for new patients. Standardizing common daily tasks frees up healthcare professionals who can use that time to focus on value-added work,proactively solving uncommon problems and daily pop-ups. Standards guard against calamity Industrialandsystemsengineersare oftenremindedthatpatientsaren’t widgets,somanufacturingprinciples mightnotalwaysapply.Andit’strue thatstandardizationmaynotbedone forallprocesses.Butstandardization canbenefitmanyprocessesthataffect patientsafety.Hospitalsshouldhave commonprocessesforhandwashing andhygiene,preparationstepsfor cardiacsurgery,labelingpatient specimens,administeringmedication, communicatingwithpatientsand cleaninganddisinfectingpatientrooms. Examplesof standardization problemsaboundinhealthcare.And nonearemoretragicthanthosethat affectlifeatitsbeginning. Takethecaseof onehospitalthat performsintracytoplasmicsperminjec- tions(ICSI).Onthedaytheclinic retrievesthewoman’seggs,thecouple hastowaitforthreehoursinthepatient roomtosignformsrelatedtoembryo cryopreservation.Whiletheroutine formwasnecessary,thewaitingtimeis unacceptable.If thehospitaldoes20 ICSIoperationsperday,thisis60hours of wastethatwilldelaypatientdischarge andkeeproomsfromopeningupfor newpatients. Standardizationalsocanbenefitthe processof labelingpatientspecimens. Thisisacriticalprocesswhereincorrect labelingcanleadtocatastrophe. ArecentarticlepublishedbyThe AmericanSocietyof Reproductive Medicinemaintainedthatfertilityclinics haveanethicalobligationtodisclose mistakesthatcouldresultinbabies bornwitha“differentgeneticparentage thanintended.”Incorrectlabeling couldleadtoinseminatingawoman withthewrongsperm,combiningthe wrongspermwiththewrongeggsor transferringthewrongembryostothe wronguterus–devastatingerrorsthat canresultinbabiesintendedforother couplesbeingbornbysomeoneelse. Suchcalamities,expertsinsist,are rare.ThebodyrepresentingCanada’s largelyfor-profitfertilityindustrysaysit isunawareof anycasesof “misdirected” embryos,butasmatteringof reportsof in-vitrofertilization(IVF)mix-upsin theUnitedStatesandelsewherehave ledtoemotionallywroughtbattlesto determinelegalparentageandcustody. In1999,aNewYorkStatewomanof Italiandescentgavebirthtotwinboys –onewhite,theotherblack.Reportedly, theclinichadn’tproperlyflushedthe pipettebetweentransfers.In2015,a womaninPolandgavebirthtoanother woman’schildafterherhusband’s spermwasmistakenlyusedtofertilize someoneelse’segg. Manyfertilitycentersusebarcodes madefrompolysilicon,thesame materialusedinglass,toprevent suchIVFmix-ups.Eachtagisabout one-tenththewidthof ahumanegg andcanbemarkedwithpatternsrepre- sentinganeight-digitbinarycode, providing256possiblecombinations. Toattachthesebarcodestoeggs, clinicsuseaproteinthatbindsthe carbohydratesonthecell’soutersurface. Followingastandardprocesstocheck thattherighteggisbeingused,the barcodeisreadusingamicroscope beforetheIVFprocedure.Thetag doesn’taffecttheeggortheembryoand isshedbytheembryowhenimplanted intothewomb. Communicationcanbeanother keystandard.AdamInternational HospitalisafertilitycenterinEgypt thatstandardizeswhatdoctorsand assistantssayintheoperatingroom beforesurgerystarts.Thishashada remarkableresultonpatients’satis- factionandmorale.Inmanycases, educatingpatientsontheirmedications isverynecessary.Itusuallyincludeshow totakethedosageandthepossibleside effects,andpropercommunicationis vital. Communicatingefficientlywith patientsandfamiliesbeforesurgery Properstandardizationremoves wastes,maintainsquality,controls variationandimprovesproductivity. Improperstandardization,however, canamplifyproblems.Formsthat patientsmustfilloutandsignoftenarea frustratingholdup,soastandardization processthataddstotheseformswillnot improvethings. GreathospitalsintheUnitedStates andJapanhaveintroducedstandards throughalllevels,includingtheirCEOs, presidentsanddirectors.Whilesenior leaderslikelywillhavelessoftheirtime coveredbystandardizedwork,many organizationshaveastandardforwhat leadersandmanagersshouldlookfor ingembawalks.Astandardizedwork processshouldbeusedtotrainthenew staffandeducatepatients. Theseguidelinescanhelpyour healthcarecenterwritetheright standards: 1. Don’t rely on previous time studies recorded at the engineering office. 2. Eliminate any wasted motion and waiting times.Don’t include any walking time in the work elements. Don’t include any non-value-added work. 3. Measure the time of each work element separately.Don’t include only the total time of the job. 4. Standards should be an output from process mapping.Human time usually should be separated from the process time. 5. Allow people to share their ideas for improving their work. 6. Use auditing to ensure people are working to the standard.If the standard is not being followed, leaders must ask why.Leaders should work with employees to improve standards and remove any obstacle. 7. Standardization should be a part of any improvement efforts to achieve the organization’s vision and goals. Forcing people to follow a standard because management needs to make things look better is not what adds value to the customer.
  5. 5. january/february 2018 29 alsoaddsvaluetohealthcareservices. Acknowledgethepersonbyname, introduceyourself,discusstheduration of stay,explainwhatyouaredoingand, finally,thankthem. Somesurgicalprocessesthatare donewithoutanesthesiarequirepatient educationandclearinstructions.Take theIVFembryotransferoperation. Thegynecologistshoulddescribethe processtothepatientandgiveher clearinstructions.Forexample,female patientsmustlieontheirbackforone hourafterthisprocedure.Shecannot moveandmustkeepherheadinaflat position.Andforthefollowingfewdays, shemusttakeseveralprecautionsand followaparticulardiet. Failuretoadheretotheseinstructions couldcausetheembryoimplantation tofail. The proper lean mindset Thepropermindsetisimportantfora leanculturetoflourish. AsLikerdescribedinTheToyotaWay, oneToyotamanagementprincipleisto “baseyourmanagementdecisionon long-termfinancialbenefitevenatthe expenseoftheshort-termfinancialgain.” Likewise,addingmorevaluetopatients isalong-terminvestment.Short-term costreductionthinkingcansabotage patientmoraleandsatisfactionanddelay treatment. Forexample,forthepurposeof economy,somelaboratoriesprocess certaintestsonceeverytwoweeks.But thiscandelayinwaysthatwillcostthe hospitalfarmorethananyshort-term savings.Onecouplehadworkedfor threeyearsbutstillhadnotachieved pregnancy.BeforedoinganICSI procedure,afertilityclinicspecialist wantedtoassessthesperms’DNA fragmentationtodeterminetheirfertil- izationability,adispersiontestthat shouldtakelabsnomorethantwodays. Butsincethelabalwayswaiteduntil ithadseveralspecimenstorunthetest onceortwiceamonth,thelaboratory tookfiveweekstodelivertheresults. Ontopof that,aftertheresultswerein, thedoctorhadtoprescribeantioxidant medicinesforthreemonthsandrepeat thetest.Thattotalsfive-and-a-half monthsofwaitingtimeforaprocessthat shouldtakethreemonthsandfourdays. Thefrustratedcoupledecidedtogo toanotherplacethatprovidedmore valueinpatientcare.Thisshort-term financialthinkingcostthefertilitycenter muchmorethanwhatitsavedviabatch processingof thespermDNAtest. The proper lean healthcare tools Whiletoolshelp,managementmethods andphilosophicalconceptscanassist yourorganizationinchoosingthe righttoolsforyoursituation.Beyond standardization,themostcommonlean toolsusedinhealthcareare5S,visual- izationandkanban. 5S(sort,setinorder,shine, standardize,sustain)isamethodof creatingaclean,well-organizedandsafe workplacefreeofclutterandwasted motion.5Sisabouteliminatingwaste, notjustmakingtheplacelooknice. Sorteliminatesitemsthathaven’tbeen usedforawhile.Setinorderorganizes whatisleftinawaythatwillmakeit easiertofindtoolsandmaterials.Agood exampleofstandardizationinthisarena isshadowboards.Theseboardsoutline toolssoit’seasytoseewhichinstru- mentsaremissing,insuringthatevery toolhasaplaceandisreturnedafteruse. Shineisaboutcleaning,whichisall aboutinfectioncontrolinhealthcare. Short-term cost reduction thinking can sabotage patient morale and satisfaction and delay treatment.
  6. 6. 30 Industrial Management People aren’t resistant to change, but they resist being changed. Leanprinciplescanbecombinedwith otherapproachesliketotalproduction maintenance.TPMhelpsensurethat machinesandinstrumentsareworking optimally.Forinstance,theultrasonog- raphymachineisacriticalinstrument ingynecologyclinics,whereafailing orbrokenmachinewilldelaypatient treatment. Analyzing failure prevents problems Amaingoalof leanistoprevent problemsbeforetheyhappen,thus improvingpatientcare.Whileanalyzing therootcauseofproblemscanprevent theirreoccurrence,analyzingfailure possibilitiescanpreventcatastrophes. Astatisticalqualitytoollikefailure modeeffectanalysis(FMEA)canidentify criticalprocessesandtheconsequence offailure.Thenit’suptomanagement tousethebestmethodtopreventthose failuresfromoccurring. Manydoctorstrackthecausesof failureaftertheyoccur.Whilesome failurescanharmpatients,otherscrush moraleandcostmoney. Asnotedabove,pregnancyisagreat example.Whennaturalpregnancy isnotpossible,thenextbestchoice isIVFtreatment,whichiscomplex andexpensive,averaging$15,000for eachfreshcycleintheUnitedStates. Insuranceoftendoesn’tcoverthe procedure,andsometimesitcanbe difficulttofindaneggdonor.Thesuccess rate,alreadylowat50percent,also dependsonthewoman’sage. Allof thesefactorscanmakeafailure aftertreatmentemotionallydevastating tothecouplesinvolved.Thismakesthe resultssharedinthepaper“Successful PregnancyOutcomeinaCaseof ProteinSDeficiency”byD.M.Lalan, M.J.JassawallaandS.A.Bhaleraointer- estingtopeoplewithsuchproblems. Theauthorsfoundthatoneoutofevery 500to3,000womenlosepregnancy duetoproteinSdeficiency,whichisan inheritedformof thrombophilia. Treatmentforthrombophiliaduring pregnancyiseasyandinvolvestaking thecorrectmedicationandinjections, usuallyaspirinandheparindrugs. Testingcostsabout$500andcansave coupleswhochooseIVFalotof time andheartbreak.If acoupledecidesto performtheadditionaltests,which cost$500,theywillbeabletoreduce theriskoffailuresinsteadofwaiting untilithappensandlosealltheeffort andmoneytheyspentinIVF.Doctors shouldhaveastandardizedprocess forwhatquestionstheyaskpatients beforetreatmentstarts.Somediseases, includingthrombophilia,canbegenetic, soquestionsabouthistoricalfamily diseasesshouldbeonthelist. Understandthathospitalsshouldn’t overproducediagnosticsandtestsand performunnecessarycheckups.That wouldbeconsideredwaste.Butwhen therecanbeahigh-riskresultfromnot testing,theriskshouldbeestimatedand testingconsidered,asintheIVF-throm- bophiliacase. Lean can bring positive change to healthcare Healthcareprofessionalsshouldnot useleanapproachestoseekdirectcost reduction.Theirmainfocusshouldbe onaddingmorevaluetopatientsand improvingquality–thecostimprove- mentswillcomeindirectly. It’sveryclearthatstandardizedwork isthefoundationofhealthcarequality. Butwhenapplyinglean,remember thatwedon’tstandardizeprocessesfor thesakeofstandardization.Wedoit forconsistentqualityandproductivity. Peopleshouldn’tbeforcedtofollowa standardwithoutaskingtheirinput. Peoplearen’tmachines,andlean practitionersalwaysshouldremember thatrespectforpeopleisanimportant partoflean. Peoplearen’tresistanttochange, buttheyresistbeingchanged,andlean toolswon’tworkwithoutthecorrect culture. Butitshouldbemucheasiertoinvolve healthcareworkersinaleantransfor- mation,becauseunlikeothersectors, peopleworkinginthemedicalindustry areintrinsicallymotivatedbythedesire tohelppeopleandsavelives.v Sustainauditstomakesurethingsdon’t slipback. Visualmanagementisaproblem- solvingandpreventiontechniquefor reducingwastes.Examplesincludelabels thatwarnabout“Caution,hotcontents” or“Warning!Riskofinjury.”Labeling specimens,asnotedabove,isagood exampleofvisualcontroltoprevent errors. Manyhospitalsusevisual managementtoidentifythestatusof patientsandtheirneedtofacilitate real-timedecision-making.Tracking boardsidentifywhichroomsareopen andletfamiliesknowwheretheirloved onesare.Somehospitalshaveautomated thisprocessanduselargedigitalscreens andsoftwareformanagingthesystem. Kanbanisamethodthatoften controlsinventorybuffers.Thesystem yieldsfewerstock-outsandbetter materialavailabilitythanotherinventory managementsystems.Inhospitals, kanbanmanagesmedicalsupplies, drugs,officesupplies,linenandother commodities. Kanbanstartedtoappearinhealthcare inthelate1980sthroughthedevel- opmentofatwo-binsystemformedical supplies.Whenonecompartmentof suppliesisempty,thenursesusethe second(orbackupcompartment)and identifythatabinhasbeenemptied. Materialhandlersnormallycheck nursingunitsuppliesonafixed schedule.Thehandlersscanthekanban cardsandtransfertherequeststothe materialmanagement’sinformation system.Foritemsstoredinthecentral warehouse,theinformationsystem generatesapicklist. Fordirectpurchases(itemssourced externally),thesystemtransmitsa requisitiontosuppliers.Finally,material handlersdelivermedicalsuppliesdirectly intotheemptybins,ensuringstock rotationineachunit. Kanbansystemssavehospitals money.OnemedicalcenterinEgypt reducedinventoryholdingvaluefrom$3 milliontolessthan$800,000.Another reducedunplannedcallsformaterialsby 50percent.

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