This document provides an introduction to Lean principles and their applications in healthcare. It discusses how Lean aims to identify and eliminate waste from processes to improve quality, reduce costs, and increase value for patients. Examples are given of healthcare organizations that have successfully applied Lean approaches to reduce wait times, infection rates, costs, and improve other outcomes. Both criticisms of Lean and its potential applications in radiology are mentioned.

1. Radiology and Lean
Leadership
Howard B. Fleishon, MD, FACR, MMM
Medical Director
Department of Radiology
John C. Lincoln North Mountain Hospital
Disclosure:
Council Vice Speaker
American College of Radiology
Learning Objectives:
1. Introduction to concepts of “Lean”
process engineering.
2. Applications of Lean principles in
Healthcare
3. Present pros and cons of “Lean”

2. “The future ain’t what
it used to be.”
Yogi Berra
“Make no mistake: The cost of our health
care is a threat to our economy. It’s an
escalating burden on our families and
businesses. It’s a ticking time bomb for
the federal budget. And it is unsustainable
for the United States of America.”
President Obama speech to the AMA, June 15, 2009

3. Bending the Cost Curve - Medicare Costs as % GDP
Redefining Health Care
“The patient's medical condition is the unit
of value creation in health care delivery”
Michael Porter
“Redefining Health Care”

4. Institute of Medicine
An epidemic of waste blights the US health
care delivery system. Despite a huge
dedication of resources to health care in
the United States, the medical system does
not deliver safe, effective, efficient,
patient-centered, timely, and equitable
care as recommended by the Institute of
Medicine.1
http://jama.ama-assn.org/cgi/content/extract/297/8/871
Institute of Healthcare Innovation
“All organizations, including health care
and Radiology organizations, are composed
of a series of processes, or sets of actions
intended to create value for those who use
or depend on them”

5. Institute of Healthcare Innovation
“Agreement is growing among health care leaders
that lean principles can reduce the waste that is
pervasive in the US health care system. The Institute
for Healthcare Innovation believes that adoption of
lean management strategies, while not a simple
task, can help health care organizations improve
processes and outcomes, reduce cost, and increase
satisfaction among patients, providers and staff.”
"We need health care that is sustainable and
excellent – both. That will require rethinking
our work and redesigning our systems of
care boldly and guided by proper theory.
Lean thinking and true patient-centeredness
are not just compatible; they are, at heart,
the very same thing.“
Donald Berwick, MD, MPP, FRCP, founder and former President
and CEO of the Institute for Healthcare Improvement

6. What is “Lean”
• Management strategy to improve processes.
• In any given process, distinguish value added steps
from non-value-added steps.
• Eliminate waste so that ultimately every step adds
value to the process.
• Evaluate processes by accurately specifying the
value desired by the end user.
• Making value flow from beginning to end of a
process based on the expressed needs of the
customer/patient.
What is “Lean”
“Lean” is the identification and steady
elimination of waste through:
 The implementation of first time quality approaches to
work.
 Standardization of processes
 Smoothing of flow
 Flexibility of work
 Long term relationships with customers and vendors
 Reduction in time leading to cost reduction and business
improvement
“Lean” Companies
Abbott Tool Works Industries Ravalg Sug F
Boeing Company Intel Corporation S&P 500 Index, RTH
Carlo Scodanibbio Johnson and Johns SSE Composite Index
Industrial Consultant NASDAQ Stanley Works
Danaher Newell Rubbermaid Steelcase Inc.
Danaher CP Nike Inc. CL B Tesco PLC
Deere Company Parker Textron Inc.
Djia Parker Hannifin C Toyota
Ford Pentair, Inc. Volkswagen
Glaxo Pfizer Wabtec Corporation
Hillenbrand Inc. Pinnacle West Capitol Wabtech
Hospira Rajvir Industries Wyeth
IBM

7. Lean Industries:
Validated Industry Averages
• Direct Labor/Productivity Improved 45–75%
• Cost Reduced 25–55%
• Throughput/Flow Increased 60–90%
• Quality (Defects/Scrap) Reduced 50–90%
• Inventory Reduced 60–90%
• Space Reduced 35–50%
• Lead Time Reduced 50–90%
*Summarized results, subsequent to a five-year evaluation, from numerous companies (more than
15 aerospace-related). Companies ranged from 1 to >7 years in lean principles application/
execution. Source: Virginia Mason Medical Center
Source: www.LeanMaps.com -- Mark Graban
Virginia Mason Production System
 Reduced lab reporting times by more than 85%
 Improved time nurses spend in direct patient care from 35
% to 90 %.
 Reduced bedsores from 8% to less than 2%
 Saved $1 million in supply expense in 2009.
 Reduced professional liability insurance 48.9 percent from
2004 to 2009.
 Pharmacy improved medication from 2.5 hours to 10
minutes, reduced incomplete inpatient medication orders
from 20 to 40 percent to less than 0.2 percent
 Saved $8 million in planned expansion projects since 2002

8. Seattle Children’s Hospital
Continuous Performance Improvement
• Cut costs per patient by 3.7 percent for a total savings
of $23 million.
• Avoided spending $180 million on capital projects by
using its facilities more efficiently.
• Served 38,000 patients, up from 27,000, without
expansion or adding beds.
• Reduced the average waiting time for non-emergency
M.R.I.’s from 25 days to 1.5 days.
http://www.nytimes.com/2010/07/11/business/11seattle.html
University of Pittsburgh
Pittsburgh Regional Healthcare Initiative
• Reduced catheter related infection rates dramatically.
• Pathology decreased staff by 28% through attrition.
• Time needed to order inventory was cut from eight
hours weekly to minutes daily.
• Stock levels were reduced by 50%.
• Overstocking and rush orders due to stock outs were
virtually eliminated.
http://www.ihi.org/NR/rdonlyres/B6EA145C-BA93-429B-9BDF 46ACE63F1B1C/0/
ShadysideSuccessStory.pdf
ThedaCare Improvement System
Collaborative Care Units
• Patient Satisfaction- from 68% to 90%
• Quality of Care- Pneumonia: 38% to 95%
• 30% reduction in costs
• Projected improvement in NPV when disseminated
throughout the system: 63% or more than $23
million

9. University of Michigan
Michigan Quality System Projects
• 2 day reduction in LOS for uncomplicated cardiac patients
• Over 30 minute per patient decrease in time spent in ER
waiting room
• 4 hour decrease (from 7 hours to 3 hours) in time from ER
MRI requisition to scan started
• 34% improvement in payments posted within 3 days of receipt
• Interventional Radiology on-time starts improved from 13% at
baseline in July 2007 to 58% in January, 2010
Ontario Wait Time Information Program
• CT avg wait time: 42% improvement
• MRI avg wait time: 12% improvement
The Application of Lean Thinking to the Care of
Patients With Bone and Brain Metastasis With
Radiation Therapy
Results and Conclusion:
 Reduced the number of individual steps to begin treatment
from 27 to 16
 Percentage of new patients with brain or bone metastases
receiving consultation, simulation, and treatment within the
same day rose from 43% to nearly 95%.
 “By implementing the ideas of lean thinking, we improved
the delivery of clinical care for our patients with bone or
brain metastases.”
http://jop.ascopubs.org/content/3/4/189.abstract

10. MRI Room Turnover
Process START: Previous patient off exam table. Process END: Current patient on table
Before: Observed Cycle Time = 17.5 minutes includes 14.5 minutes waiting for patient
Transporter
Transport Get w/c, Transport
prev Pt to cart if Pt to MRI
Unit needed
START
Tech
Clean, Patient Position,
resupply WAIT FOR PATIENT to Exam Instruct END
room Table Patient
After: Observed Cycle Time = 4.1 minutes, includes 0 minutes waiting for patient
Patient “on Transport
Transporter
Get w/c, Transport
cart if deck” before prev Pt to
Pt to MRI procedure Unit
needed
Clean, Patient
START resupply to Exam
room Table
Position,
Instruct
END
Tech
Patient
TPS - Basis for Lean
The Toyota Production System (TPS) is a
major part of the more generic "Lean
manufacturing". TPS is the philosophy which
organizes manufacturing and logistics at
Toyota, including the interaction with
suppliers and customers.

11. Learning to Lead at Toyota-4 Principles
• There is no substitute for direct observation
• Proposed changes should always be structured as
experiments
• Workers and managers should experiment as
frequently as possible
• Managers should coach, not fix
http://hbr.org/2004/05/learning-to-lead-at-toyota/ar/1
Lean Manufacturing
is a manufacturing philosophy which shortens the time between the customer
order and the product build / shipment by eliminating sources of waste.
Business as Usual
CUSTOMER Waste PRODUCT
ORDER BUILT & SHIPPED
Lean Manufacturing Time
CUSTOMER PRODUCT
ORDER BUILT & SHIPPED
Waste
Time (Shorter)
“Waste” in TPS
The original seven wastes are:
1. Transportation
2. Waiting
3. Inventory
4. Motion
5. Over Processing
6. Defects
7. Rework
There has now been identified an 8th Waste
8. Unused Human talent

12. “Lean” and Quality
"It turns out--what we've learned," summarizes
Kaplan, "is that the best way to improve quality
is to eliminate non-value-added variation. This
is a way, a method for that. And it's working!“
Gary Kaplan, MD
Chairman and CEO
Virginia Mason
Lean Thinking as the Scientific Method
Applied to Daily Work
Scientific Method Lean Thinking
• Observation • Go see, ask why, respect
• Hypothesis • Plan P
• Intervention • Do D
• Results/reflection • Check/reflect C
• Revise hypothesis • Adjust A
• New intervention… • Repeat PDCA cycle…
• Structured abstract • A3 report, Value Stream Map
35
MANAGEMENT
SYSTEMS
MINDSET METHODS

13. Culture Change
Culture Shift
Traditional Culture Lean Culture
• Function Silos • Interdisciplinary teams
• Managers direct • Managers teach/enable
• Benchmark to justify not • Seek the ultimate performance,
improving: “just as good” the absence of waste
• Blame people • Root cause analysis
• Rewards: individual • Rewards: group sharing
• Supplier is enemy • Supplier is ally
• Guard information • Share information
• Volume lowers cost • Removing waste lowers cost
• Internal focus • Customer focus
• Expert driven • Process driven
Applications in Radiology
• Standard Work
Protocols
Policies
Structured reporting
Standard Lexicon
• Streamline workflow in Billing and Collections

14. Criticisms of Lean
• Standardization versus patient variability
http://online.wsj.com/article/SB10001424052748704913304575371210975895460.html
• Standard work flow and lack of inventory and
may not be able to readily adapt to rapid
changes in demand (i.e ER).
http://online.wsj.com/article/SB10001424052748703792704575367003265429096.html
?mod=googlenews_wsj#articleTabs%3Darticle
• Reiteration of past methods- Six Sigma, CQI,
etc.
Summary
• “Lean” is a method of process
engineering based on the Toyota
Production System.
• As Radiology group leaders we should
be aware of “Lean’s” increasing profile
in healthcare.
• Potential applications in Radiology
ASRT Code:
VAD0110025

15. Books: References
• Womack, Jones. Lean Thinking. (An overview)
• Liker. Toyota Way. Liker, Meier. Toyota Way Fieldbook. Liker, Hoseus. Toyota Culture.
• Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use)
• Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use)
• Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri)
• Rother, Shook. Learning to See. (Value stream mapping)
• Baker, Taylor. Making Hospitals Work (From Lean Enterprise Academy, UK)
• Graban. Lean Hospitals. (Applies Lean principles to health examples)
Articles:
• Kim, Spahlinger, Kin, Billi. Lean health care: what can hospitals learn from a world-class automaker? J
Hosp Med. 2006;1:191.
• Kim, Hayman, Billi, Lash, Lawrence. The Application of Lean Thinking to the Care of Patients With
Bone and Brain Metastasis With Radiation Therapy. J Oncology Practice. 2007;3:189.
• Kim, Spahlinger, Kin, Coffey, Billi. Implementation of Lean Thinking: One Health System's Journey.
Joint Commission J Quality and Safety 2009;35:406.
• Bush. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.
• Spear. (all Harvard Business Review) Fixing Health Care from the Inside, Today (9/05); Learning to
Lead at Toyota. (4/04); Decoding the DNA of Toyota Production System. (9/99)
• IHI. Going Lean in Health Care
www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare
Web:
• Michigan Quality System at UMHS: med.umich.edu/mqs
• Lean Enterprise Institute: www.lean.org webinars, books, meetings…
• Lean Healthcare Value Leaders Network www.healthcarevalueleaders.org
• Lean Enterprise Academy (UK): www.leanuk.org
• Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm