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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.
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
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,
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.
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.
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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Healthcare is ripe for lean

  • 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. 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. 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. 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. 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. 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.