Application of Lean principle for improving quality in healthcare setting.

1. Healthcare Operations Management
Title : Lean Management in Healthcare
Level of Study : CIQ Level -7/ Postgraduate

2. Lean Management and ways to improve
operational performance in Healthcare
Dr.Syed Raza , MD, FRCP, FACC,FESC
Consultant Cardiologist , HOD Medicine
PG Diploma in HCM
American Board in Medical Quality

3. 1. Quality Management (QM)
2. Quality Assurance (QA)
3. Quality Control (QC)
Numerous activities are aimed at maintaining the production of
quality In principle, three levels of organization of these activities
can be distinguished. From the top down these levels are:

4. Quality
Assurance
Proper Quality Management implies
consequent implementation of the next
level:
Quality Assurance.
The ISO definition reads: "the assembly
of all planned and systematic actions
necessary to provide adequate confidence
that a product, process, or service will
satisfy given quality requirements."
The result of these actions aimed at the
production of quality, should ideally be
checked by someone independent of the
work: the Quality Assurance Officer.

5. Quality Control
A major part of the quality assurance is
the Quality Control defined by ISO
as "the operational techniques and
activities that are used to satisfy quality
requirements. " An important part of the
quality control is the
Quality Assessment: the system of
activities to verify if the quality control
activities are effective, in other words:
an evaluation of the products
themselves.
Quality control is primarily aimed at
the prevention of errors. Yet, despite all
efforts, it remains inevitable that errors
are be made. Therefore, the control
system should have checks
to detect them.

6. Reliability - providing consistent, accurate and
dependable service(s); delivering the service that
was promised.
Responsiveness - being willing and ready to
provide service(s) when needed.
Security - physical safety; financial security;
confidentiality.
Tangibles - the physical aspects of the service such
as equipment, facilities, resources.
Understanding the customer - knowing individual
customer needs.
Access - the ease and convenience of accessing
the service(s).
Communication - keeping your users informed;
listening to your users.
Competence - having the skills and knowledge to
provide the service(s).
Courtesy - politeness, respect, consideration, and
friendliness of staff at all levels.
Credibility - trustworthiness, reputation and
image.

7. Why Is Quality Important?
• Underuse – failure to provide a service whose benefit is greater than its risk.
• 54.9% of patients receive recommended care.
• Overuse – use of service when risk outweighs its benefits.
• Uncritical use of antibiotics, especially in consumer products.
• Misuse – risk that service is provided badly, reducing benefit to patient.
• Medical errors, medication errors.

8. Improving
Quality & Patient
Safety: Broad
Principles
• Systems versus individuals
• Swiss cheese model
• Learning from errors
• Near misses
• Communication
• Checklist
• Set of tasks done in a standardized
manner

9. Swiss Cheese
Model

10. Error
Causation
and
Prevention

11. Near Miss
analysis

12. Performance Improvement Methodologies:

13. Focus on Quality
• Improving processes requires simultaneous concentration on Costs and Quality
• Quality: High standards, excellence, and the ability to meet and exceed customers’
expectations
• Healthcare quality metrics:
• Patient Outcomes
• Patient Safety
• Financial
• Administrative
• Patient Flow

14. Dimensions
of Quality
Safety
Effectiveness
Patient
-centeredness
Equity
Timeliness
Efficiency

15. Lean Six Sigma in Healthcare
• Six Sigma is a metrics-driven system used to reduce medical
errors and remove defects from processes involved in delivering
care
• Lean focuses on eliminating waste
In the last two decades, the two systems have been combined
into the hybrid improvement process called “Lean Six Sigma

16. Advantages of Lean over six sigma
• Lean is the better overall approach for improvement in
healthcare because it values all members of the patient care
team and can be implemented by anyone.
• Unlike Six Sigma, Lean does not require advanced statistical
methods, costly training, or expensive platforms and systems.
More importantly, lean values can be applied incrementally on a
continual journey toward value-based healthcare.

17. Six Sigma
• “Data-driven quality methodology that seeks to eliminate variation from a process.”
• Large HR component
• Quality training and personnel
• Leadership
• DMAIC

18. DMAIC
Define
Define – delimit
scope of work
and time
frames for
completion.
Measure
Measure –
create and
apply measures
and metrics.
Analyze
Analyze –
assess and
flowchart the
process.
Improve
Improve –
specify the
steps to be
taken to meet
goals.
Control
Control –
assure
permanence of
the
improvements.

19. Sigma Levels and DPMO
691,500
308,500
66,800
6,200
230
3.4
1
10
100
1,000
10,000
100,000
1,000,000
1 2 3 4 5 6
Defects
per
Million
Opportunities
Sigma Level
Figure 4-7

23. Basic lean principle : since 1990s
• Provide quality services to patients
• Reduce or remove wastes

24. Performance
Improvement
Methodologies:
Lean
Stresses employee participation, reliance
on data and use of careful analysis to
drive change
Involves reducing waste so only the work
that adds value to a system or process is
performed
Lean culture is very different from
traditional medical culture
Leaders must drive the process

25. Where Does Lean
Originate?
• Developed by Toyota as the Toyota
Production System (TPS) over the last
50 years
• Study of TPS led to academics
defining the approach as “Lean”
• The application of Lean is not new –
principles have been used in many
industries.
• In the last ten years, increasing
application of the Lean approach in
healthcare

26. • The Toyota Production System (TPS), also known as
the Lean management system (Lean), is already
helping health care organizations provide high-quality, low-cost
care, and it promises to do far more. However, the potential
benefits of TPS/Lean are endangered by a failure of many to
understand it

27. Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Map the total
customer/
provider
value stream
Make value
flow
with no
interrup-tions
Pull what
you want
when you
want it
Search for
perfection
with no
waste
Establish
value in the
eyes of your
customer

28. 5 key lean principles
• The five principles are considered a recipe for improving workplace
efficiency and include:
• 1) defining value
• 2) mapping the value stream
• 3) creating flow
• 4) using a pull system
• 5) pursuing perfection

30. Wastes in a Healthcare Process
Lean waste Examples in radiology
Defects Running unnecessary scans; forms not being signed,
Overproduction Undertaking multiple scans
Excess inventory Extra supplies
Excess processing The process for ringing porters in the evening is to ring the Help Desk and then to
be routed to the porters; entering duplicate information; printing paper reports to
send in post
Unnecessary motion Time spent looking for staff; entering duplicate information; looking for parts and
forms; interruptions from other staff
Unnecessary
transportation
Transportation of scan results in post
Waiting Waiting for referrals/scans; waiting for reports/signatures; waiting for patients,
doctors, porters
Underutilised staff Helpers in waiting rooms; secretaries waiting for reports to be signed

31. Advantages of Lean in Healthcare
• Lean in healthcare has improved patient satisfaction, increased
revenue and decreased overtime work.
• Likewise, as a result of deploying Lean principles,
improvements have been recorded in processing paperwork
and scheduling appointments.
• Hospitals, clinics and healthcare centres have successfully
deployed lean in various areas of their operational processes.

32. Why lean in healthcare ? Advantages
• 1. Improves efficiency
• 2. Provides better quality service
• 3. Improves patient safety
• 4. Reduces waste
• 5. Saves cost

33. Advantages of lean in healthcare
• 6. Better communication between top management and frontline
staff
• 7. Front line staff more dedicated and enthusiastic in their work
• 8. Staff become more innovative
• 9. Better team work
• 10. Continuous improvement
• 11. Staff satisfaction
• 12. Patient satisfaction

34. Lean example 1
• Denver Health Eastside Clinic observed that a good number of
its patients did not show up for maternal postpartum check-ups
due to long waiting times and transportation barrier. As a
solution to this problem, the clinic merged mother and infant
appointments. This drastically reduced the number of patients
that did not turn up for appointments from 50% to 5%.

35. Lean example 2
• One great example of lean in healthcare is the Virginia Mason.
By deploying lean tools, the hospital was able to implement a
Patient Safety Alert (PSA) initiative. This system was devised
for staff to be able to report problems that involve patient safety.
Once reports were made, they were investigated, and
necessary solutions implemented. As such, Virginia Mason was
able to reduce their liability claims by 74% from 2005 to 2015.

36. Lean example 3
• a breast cancer screening centre applied lean practices to
implement an interdisciplinary approach to its treatment
processes. As such, patient call back for unnecessary biopsies
reduced from 10% to 5%. Additionally, breast biopsy-related
costs reduced by 35%.

37. Lean example 4
• nurses in ThedaCare were able to increase their time with
patients by 70%. By implementing Lean principles, patient
safety was improved, and patient rooms redesigned. Hospital
rooms were equipped with ceiling lifts and beds were fitted with
alarms and scales. Also, supplies, electronic record-keeping
systems and medications were transferred to patient rooms.

38. More Lean Tools
• Poka-yoke: This is a particularly useful lean tool in healthcare. It
helps in mistake prevention.
• Work cell optimisation: Useful to reduce the time needed to
complete tasks. Thus, an indispensable lean tool in healthcare.
• The 5-why and the Ishikawa diagram are other useful lean tools
used for cause analysis. The Ishikawa diagram helps to identify the
causes of errors. Then, it further divides these causes into groups in
order to streamline and determine the most likely cause of the
error(s) identified. The 5-why method is used hand in hand with
Ishikawa diagram to question “why” errors are occurring in
healthcare processes.

39. Lean Management tools in healthcare
• Flowcharts
• Visual management.
• The 5S method. This method is one of the most popular lean
tools for healthcare and other industries alike.

40. Flowcharts
• One of the lean tools for healthcare is flowcharts clinical
processes. A process is a series of activities that translate data
inputs to an output. Healthcare organizations should identify
clinical processes in which patients are directly involved.
• The objective of flowchart clinical processes is to define lines of
action that would enhance quality and safety levels for patient
care.

41. Visual Management
• Another lean tool for healthcare is visual management. Visual
management involves the use of colours, pictures, signs,
graphics, light and sound. They are used to monitor the process
and send feedback where there are disturbances. They are also
used to evaluate the current state of the process against the
desired state.
• Also, visual management is used to show critical conditions. For
example, colour blue indicates the operating room is sterile
while the colour red indicates it is non-sterile. It is one of the
most useful lean tools for healthcare.

42. 5 S Method
• This method is one of the most popular lean tools for healthcare
and other industries alike.
• It aims to create an organized workplace so that errors can be
reduced during a process. The 5S method as a lean tool for
healthcare eases the flow of values in a process. In addition, it
makes use of 5 steps that help to reduce waste and keep
clinical processes organized.

43. Methods of Analyzing Performance
• Trend Analysis: How are we performing over time?
• Benchmarking: How do we compare to our competition?
• Benchmarking: the process of identifying best practices
and comparing performance relative to others, with the
intent of making improvements

44. De-bottleneck
• De-bottleneck: To eliminate a constraint.
• Example: a nurse takes 7 minutes for a specific procedure. When analyzing
the process, the nurse spent 3 minutes waiting for the ADT system to respond
to her query about the patient. Eliminating this bottleneck can save 3
minutes.
• Control charts show data over time, relative to averages and upper and lower
control limits.
• Understanding standard deviations are key to improving performance and
eliminating constraints

45. Lean Process
• A quality process focused on:
• Improving quality
• Improve operational processes to become faster and more flexible
• Reduce waste
• Produce in smaller lot sizes (flexibility)
Increase speed and reduce cycle times

46. Identify Sources of Significant Deviation
• Significant deviation: outside of statistical norms
• Was it related to common causes, or special causes?
• Was the deviation due to:
• Changes in staffing mix or levels?
• Higher demand or patient volumes?
• System or equipment downtime or glitches?
• Modifications in supplies or resources employed?
• Different employees?
• Related to time of day or day of week?

47. Six Sigma vs. Lean
Table 4-2

48. What does it do to our patients?
• When a patient experiences a service it is either good - and therefore what they
expect - or it is bad. Patients do not experience “averages”
• As consumers in the outside world we have expectations of good quality and service, if
these expectations are not met then we take our business elsewhere…
• In health our patients do not readily have that choice.

49. Two Elements to Every Job
Value Adding
Valuable Effort
Costs Time
Costs Money
Adds Value
VALUABLE
Non-Value Adding
Valueless
Effort
Obvious
Waste
Costs Time
Cost Money
Adds No Value
WASTE

50. • In the Analyze phase, the absence of concrete statistical data sometimes can make the
identification of a root cause difficult. In those scenarios,
• The 5 WHYS – asking “Why?” five times – along with a cause-and-effect diagram, can make
the task more manageable. The 5 Why’s tool also can help uncover the process dynamics and
the areas that can be addressed easily.
• Root Cause Analysis RCA is a way of identifying the underlying source of a process or
product failure so that the right solution can be identified. RCA can progress more quickly
and effectively by pairing an Ishikawa diagram with the scientific method in the form of the
well-known plan-do-check-act (PDCA) cycle to empirically investigate the failure.
Tool 3: ROOT CAUSE ANALYSIS,
ISHIKAWA DIAGRAMS AND THE 5 WHYS

51. Fishbone Diagram

52. Continuous quality improvement
with PDCA
Depiction of the PDCA cycle (or
Deming cycle). Continuous quality
improvement is achieved by
iterating through the cycle and
consolidating achieved progress
through standardization.
Time
Quality
Improvement

53. Deming cycle
Deming cycle (or circle,
wheel) is know as well as
Plan-Do-Check-Act Cycle
(PDCA Cycle). It is an
iterative 4-step
management method used
in business for the control
and continual improvement
of processes and products.

54. FOCUS/PDCA
(Cont’d.)
Plan – create an
implementation
plan for taking the
process to the next
level.
Do – implement
and test the new
process.
Check – evaluate
the measures used
and assess
outcomes.
Act – assure
continuation of
newly implemented
process, if
successful, or redo
the process, if not
successful.

55. FOCUS PDCA
• Is a management method, developed in the healthcare industry, used to improve
processes. Created by the Hospital Corporation of America (HCA), it is a systematic
process improvement method. Through FOCUS-PDCA, a knowledge of how a
process is currently performing to meet customer needs and expectations is used
to plan and test process changes.
• FOCUS-PDCA is an extension of the Deming or Shewhart Cycle which includes
Plan-Do-Check-Act

56. FOCUS/PDCA
Find – identify a
process problem.
1
Organize – put
together a team to
work on process.
2
Clarify – use
techniques to clarify
the problem:
• Geographic mapping
• Flowcharting
3
Understand –
measure and collect
data to document the
problem.
4
Select – identify
process
improvements for
implementation.
5

57. Why use FOCUS PDCA?
• The FOCUS PDCA method works well in a number of situations, and in particular when
there is a highly technical or complex work environment or task.
The advantages include:
• It does not require in-depth expertise, even when working with highly technical or
scientific processes.
• A wide range of people can be involved, bringing additional expertise to solving the
problem.
• The method can be learned quickly.
• It provides a framework that guides improvement efforts.
• It keeps everyone focused on the area and problem being addressed.
• It clarifies the goal of the project for everyone involved.
• There is accountability for completing tasks.
• It supports a culture of continuous improvement.

58. Kaizen
With Kaizen, “continuous improvement”
Kaizen is all about fully utilizing the individual talents and specialties of your team
members to constantly spot and act on areas where there is room for improvement.
All manufacturing stages are monitored and measured, observed and noted, and
eventually tweaked to provide maximum output for input and to save time.

59. Kanban
Kanban is a production system in which cards are used to represent the materials
within each stage of production.
The point is to provide a visual indication of your processes and ensure that flow is
maintained evenly.
Goods and materials within a stage of production are replaced when their Kanban
card is moved, indicating need at that stage.

60. Muda
• Finally, Muda, or waste, is the primary elimination focus of all of these and other
LEAN practices.
• With every decision, think about whether you are creating or minimizing waste. If
your action might create more waste (this can be in terms of time, money, or
materials) in the long term, even for a short term benefit, it’s probably best to ditch it.

61. Operations Management & Quality Improvement

62. Operations Management Must Focus
on Improvement
• To Improve: to make something better
• Continuous Improvement: a constant focus on achieving better outcomes
• In healthcare, managers must balance demands of managing current operations with
improving for the future
• This is especially important with ACA, where payment depends on improvements in care
quality

63. Operations Management – Tools & Techniques
Reduce Costs
Reduce Variability/Improve
Logistical Flows
Process Engineering
Flowcharts
OM Objective
Increase Productivity
Improve Quality
Streamline Business Processes
Toolkit
Optimization/LP
Location Analysis/Minimization Models
Break-even analysis
Sensitivity Analysis
Process Engineering
Forecasting/Demand Estimation
Capacity Analysis
Simulation
Control Charts
Productivity Analysis
Time and Motion studies
Staffing Models
Queuing Models
ROI Models
Business Planning
Wait Line Minimization Models
Statistical Process Control
Root Cause Analysis
Six Sigma
Customer Service Levels
Figure 4-1

64. Business Process
• A process is how work gets accomplished
• By fixing the process, you improve performance
• Set of activities and tasks that are performed in sequence to achieve
a specific outcome
Input Transform Output

65. Process Improvement Methodology
Collect quantitative
& quantitative
data
Create As-Is and
To-Be
Process Maps
Observe process
flows
Benchmark
Results against
Best Practices
Analyze
bottlenecks and
Other issues
Identify and
prioritize
improvement
opportunities
Develop
Alternatives, prototypes,
Pilots; Adjust as
necessary
Prepare
Recommendations
and Reports
Plan & Prioritize
Collect & Analyze
Benchmark
De-bottleneck
& Pilot
Figure 4-4