Mark Graban provides an overview of how lean thinking can help hospitals by reducing waste and errors. He discusses the need for lean in healthcare given constraints on resources and high rates of preventable errors. Graban also shares lessons learned from his experience implementing lean as an industrial engineer and consultant, emphasizing the importance of engaging employees and focusing on systems rather than individuals when problems occur.

1. “How Lean Thinking Helps Hospitals”
For Utah State University Student Lean Group
Mark Graban
Senior Fellow, Lean Enterprise Institute
Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”

2. Agenda
• Lean in Healthcare
– The need for Lean in Healthcare
– Principles that apply in Healthcare
– Examples
• Career Lessons Learned
– As an Industrial Engineer
– As a Lean Implementer
• Q&A

3. ?
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4. Engineering and Medicine…
Surgical Nurse as “Caddy”
Frank B. Gilbreth (1868-1924)

5. Henry Ford - 1922
“In the ordinary hospital the nurses must make useless
steps. More of their time is spent in walking than in
caring for the patient.”
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6. Lean is Fundamentally About:
People doing People facing People managing
work problems other people
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7. First Things First…
“Start from need.”
– Taiichi Ohno, Toyota
(1912-1990)

8. Why Lean for Healthcare?
No waiting
No waste
Zero harm
Source: an NHS hospital, UK

9. Resources are Strained
“Every day, we are holding, on average, 12
to 20 admitted patients, who have been in
our department for days awaiting hospital
beds.”

10. Employees Are Harder to Find
• Medical Technologists
– Shortfall of 10,000 per year
– 40% eligible to retire between 2005 and 2010
• Nurses
– 100,000 vacant positions in the U.S.
– 4x that many expected by 2020
• Pharmacists
– 7.4% vacancy rate per the American Hospital
Association
Not enough employees or
too much waste?

11. Too Many Errors Occur
• Adverse events in 3.7% of hospitalizations(1)
– 13.6% of those led to death(1)
– 53-58% are preventable(2)
• Death resulting from preventable error occurs in 1 of 400
hospitalizations
• (1): Brennan, Leape, et al, New England Journal of Medicine
• (2): To Err is Human, Institute of Medicine
One per week in a typical hospital

12. Many Errors are Preventable
• Nosocomial Infections
– a.k.a. “Hospital-Acquired Infections”
(HAI)
– 5 to 10% of hospitalizations
• 10% of these are serious bloodstream
infections
• 87,000 to 350,000 die annually
– “Can be prevented through improved
hygiene and proper line insertion
standards” (1)
• Allegheny: reduced bloodstream
infections by 68% through standard
methods and supplies
• (1): U.S. Centers for Disease Control

13. Remember This:
The problem
is the process
(or lack thereof)…
not the people

14. Applications of Lean in Healthcare
• Laboratories (Core Lab, Blood Bank & AP)
– Reducing Turn Around Times and Errors
• Operating Rooms
– Reducing changeover times, increasing utilization
• Inpatient Care
– More time for patient care, fewer falls & infections
• Outpatient Cancer Treatment
– Reducing patient delays, increasing capacity
• Pharmacies
– Reducing errors, improving response
• Emergency Departments
– Reducing diversions, improving flow

15. Lean Methods that Apply
• Identifying and • Quick Changeover
eliminating WASTE • Employee Involvement &
• 5S and Visual Engagement
Management • Heijunka
• Kanban • Improving Flow
• Standardized Work (Reducing Batching)
• Kaizen • Value Stream Mapping
• “5 Whys” Problem Solving • Flow layouts
• Error Proofing • “Go to Gemba”
• Spaghetti Diagrams • Time Studies

16. The Iceberg of Lean

17. “Equally Important Pillars”
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18. “Gemba”: The Actual Place
“Toyota managers
should be sufficiently
engaged on the
factory floor that they
have to wash their
hands at least
three times a day.”
Taiichi Ohno
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19. “Gemba is for Everyone”
“…Kaplan tours the
hospital daily looking
for problems and
solutions. Everyone is
encouraged to look for
changes to make work
more efficient.”
- Virginia Mason CEO Gary Kaplan
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20. Patients
(Gemba)
Walkway over
tracks
Parking
Garage
Executive
Offices
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21. “Convis became the first
North American to head a
Toyota manufacturing plant
when he was put in charge
of the Georgetown facility.
He responded to the
promotion by moving his
office from the admin
building adjacent to the
Georgetown plant to the
center of the factory floor.”
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22. The Quaid Case –
Heparin/Hep-Lock
Hospital CMO:
“This was a preventable error,
involving a failure to follow our
standard policies and procedures,
and there is no excuse for that to
occur at Cedars-Sinai.”
Was this the first time
the policies and
procedures were not
followed?

23. The Quaid Case –
Heparin/Hep-Lock
New Design
Old Design

24. Case Example
• Virginia Mason Medical Center (2004)
– Mary McClinton died after cleaning solution was injected (not
dye)
– Identical looking clear syringes together on tray
• “Mistakes will happen,” he said, sadly. “We are exceptionally
human.”
– Knew about same color syringes 2 YEARS before fatal error
occurred
• Had switched from brown cleaning solution to clear
– Radiology tech MENTIONED the problem to a supervisor 2
MONTHS before the fatality
• Why does this happen? How can we prevent this?

25. The Need for Lean Problem
Solving

26. By Adopting the Lean Approach
• Asked Key Questions:
– Whose responsibility is it to stock supplies?
• Add standardized work
• Establish kanban system
– How do we make it obvious something is missing?
• Visual management
– How do we manage the system and hold people
accountable to the standardized work?
• Lean management system

27. Toyota’s Chairman
Fujio Cho
Three Keys to Lean Leadership
• Go See
– “Senior Management must
spend time on the front lines.”
• Ask Why
– “Use the “Why?” technique daily.”
• Show Respect
– “Respect your people.”
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28. It’s The System
“You respect people, you “Human error is
listen to them, you inevitable. We can
work together. You never eliminate it.” We
don’t blame them. can eliminate problems
Maybe the process was in the system that make
not set up well, so it it more likely to
was easy to make a happen.”
mistake.”
– Gary Convis, President TMMK – Liam Donaldson, WHO World
Health Alliance for Patient
safety
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29. “I’ve worked here for
six years and this is
the first time
anyone has asked me
what I think about
anything.”
Registered Nurse
15 yrs experience
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30. Engaging Employees
From Locked Box To Visual Idea System

31. Kaizen “Wall of Fame”
Area:
STL
Kaizen Wall Date:
5/31/07
of Fame
What was the Problem?
For disposal of pipette tips, the only containers we had were “sharps” containers. This
Adds extra disposal cost, as the tips are not sharp. The container hole was also
Hard to get tips into.
What was changed, improved, implemented?
Create biohazard bag holders out of urine jugs, cut the tops off.
Photo/Diagram:
Old Style
Container
New
Container
What were the benefits? Safety? Quality? Time? Waste? Cost?
Reduces cost since we aren’t doing unneeded sharps disposal and we aren’t throwing
the containers away each time. No safety risk.
Easier to get tips into container (less motion and less arm strain, since the
Container is lower and easier to get into). Tips can be dumped into a larger
Biohazard bin or we can replace the bag.
Who was Involved?
Gretchen, Beth, Janie, Franke
Source; Children’s Medical Center, Dallas 31

32. ThedaCare’s Lean Leader Traits
• For ThedaCare’s “steady state”
– Patient
– Inquisitive
– Keenly interested in problem solving
– Good communicator
– Mentor who likes to see people success and
wants to be in the middle of the action, not
behind a desk
– Calm, deliberative problem solver
• Source: On the Mend (2010, Lean Enterprise Institute)
• Fox News Videos: http://lnbg.us/1D0
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33. Lack of Lean Leadership
“This [lean] is not the
standard model executive
being produced by U.S
business schools, much
less American medical
schools.”
– Toussaint and Gerard, On the Mend
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34. ThedaCare’s Results
• True North:
– Customer Satisfaction, Safety/Quality,
People, Financial Stewardship
• Saved $27M in first four years
• Increased margin from 2% to 6%
• Improved “door-to-balloon” time 92 min to 37 min
• Lower cardiac surgery mortality
• Fewer babies born pre-term
• Higher staff satisfaction
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35. The Working World
Technical Content Relationships
Lean Tools Communication
Change &
Results
• Cannot communicate enough
• “Show, supervise, set free”

36. Mark’s Lessons Learned (1)
• Don’t be the lone “Expert,” get everyone involved
• Great ideas don’t matter if people can’t agree
• Understand an organization’s capacity for change
– “Have the right amount of impatience”
• Observe first, then propose solutions
• Solving problems rather than “doing stuff”
– Choose the right problem and define it properly
– Numbers and results for your resume

37. Mark’s Lessons Learned (2)
• Lean is a management system and philosophy, not just
“tools”
• Does your employer really want to “be Lean”??
• Don’t rely just on “events”
• Get direct supervision experience early (but not first)

38. Why Work in Healthcare?
• Less likely to be “offshored”
• As a “Lean” person, you can make a difference
• Incredibly interesting, rewarding work
• Impact people’s lives
– Patients
– Hospital Staff
– Medical Professionals
• Help solve a high-priority societal issue

39. Q&A
• Email:
– mgraban@lean.org
• Lean Enterprise Institute:
– www.lean.org
• Healthcare Value Leaders:
– www.healthcarevalueleaders.org
• Blog:
– www.leanblog.org
• Twitter:
– www.twitter.com/LeanBlog
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40. About LEI
• Lean Enterprise Institute, Inc. (LEI) is a nonprofit
education, publishing, conference, and research
organization founded by James Womack, Ph.D. in 1997
to promote and advance the principles of lean thinking in
every aspect of business and across a wide range of
industries.
• Through its publications, summits, conferences,
workshops, webinars, online forums, and website
resources, LEI helps organizations transform themselves
into lean enterprises, based on the principles of the
Toyota Business System.
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