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.

Healthcare is ripe for lean

BY MOHAMMED HAMED AHMED SOLIMAN

january/february 2018 25
Lean thinking is a set of concepts, strat- 95 percent and saving $1 million. The many opportunities for improvement in
egies, principles and tools that can deliver University of Pennsylvania Medical healthcare.
the most value for customers while Center reduced hospital-acquired infec- In medical care, any process that
consuming the fewest resources and fully tions, saving 57 lives, reducing how doesn’t provide patient care should be
using the knowledge and skills of the long patients remained in intensive considered nonvalue-added. Examples
workforce. As defined by Mark Graban, care and cutting costs by more than $5 include doctors who stand in the
author of Lean Hospitals: Improving Quality, million over two years. ThedaCare in diagnosis room waiting for someone
Patient Safety and Employee Engagement, lean Wisconsin reduced patient waiting time to bring a missing instrument, rework
healthcare means delivering the most for nonemergent orthopedic surgery caused by defects (bringing the wrong
value to patients while consuming the from 14 weeks to 31 hours, improving drug or incorrect dosage, which can harm
least resources and maximizing the use its inpatient satisfaction score from 68 patients), storing drugs for adults in the
of people skills and knowledge. Lean percent to 90 percent. Palo Alto Medical newborn intensive care unit and failed
healthcare strives to improve quality, Foundation in California reduced blood draws that need to be redone.
prevent errors and make patients safer, waiting time for screening colonoscopies Underutilization of human talent
all while removing wastes and the possi- from six weeks to less than 24 hours can include a laboratory physician who
bility of defects. while reducing cost per patient by 9.5 draws specimens or loads them on the
After all, defects in healthcare can be percent. diagnostic device. Young assistants
catastrophic, threaten lives and directly Lab productivity can be increased by can do those jobs while the physician
affect patient safety. Defects or mistakes improving turnaround time, the time analyzes and troubleshoots the test
can lead to improper sterilization, from when a patient’s sample is drawn results.
dispensing the wrong drugs to the until he or she learns the results. Poor lab Nurses should spend their time
wrong patient, incorrect drug dosages or layout blocks the flow of samples. Many charting with patients, discussing their
improper diagnosis – all of which can be labs use batch processing, which keeps health with them, describing proper drug
hazardous to your patients’ health. samples waiting before inspection and dosage and administration and other
diagnosis. in-patient care issues. Unfortunately,
Proof from the front lines Replacing batch processing with many nurses waste a lot of time walking
Lean can apply throughout a medical one-piece flow can save thousands between departments, searching for tools
system: Opportunities for improvements of dollars and dramatically reduce and bringing patients drugs. Some of
can be found in laboratories, clinics, turnaround time. Graban’s Lean Hospitals these activities can be done by people
diagnosis rooms, operating rooms, cited a case where moving the specimen with less expertise to save money and
surgical rooms and intensive care units. collection point in the lab closer to the allow nurses more time with patients.
Before lean, “improvement” meant diagnostic device slashed laboratory One simple process improvement
doing work faster. But accelerating work turnaround time by 29 percent. Replacing involves bags – yes, bags. In some
doesn’t necessarily make things better Speedier turnaround time also batch hospitals, nurses carry many of their
and, in fact, can decrease quality. Making benefits surgical centers. Many hospitals processing tools and instruments in a waist bag,
people work faster can overburden them, prepare for the next surgery in the with one- which saves them from walking here and
leading to an unbalanced workload that downtime between procedures. Applying piece flow there to find the necessary items.
can trigger more mistakes, errors and the Toyota Production System’s tool can save Such an improvement also helps
create wastes in other linked areas. known as single minute exchange of thousands of reduce waiting, the most common waste
Lean, on the other hand, works by die (SMED) prepares the next room dollars and in all hospitals. The waste of waiting is
taking out wastes and the non-value- for surgery while the current one is dramatically acutely obvious to patients who wait to
added steps to improve value-added in process, gathering all the tools and reduce make an appointment, wait when they
processes. Therefore, lean healthcare is instruments into their proper places. turnaround arrive at the office, wait to pay bills and
not about cutting costs by reducing the This reduces expensive downtime. time. wait to get discharged. Doctors often
level of service and the quality of care. These achievements prove that wait for the tools they need. Others wait
Instead, lean healthcare puts more value applying lean in healthcare can deliver for pharmacy orders, medications and
in patient care. Improving quality is the results in terms of patient safety and care, tools that are properly sterilized. All of
key to saving costs. all while reducing costs. this delays patient care.
Graban highlighted some excellent Hospital layout greatly affects trans-
achievements in Lean Hospitals. It’s all about the waste portation waste. A nurse on an intensive
For example, Allegheny Hospital in The eight types of waste (the traditional care unit might average walking from 7
Pennsylvania reduced central line blood- seven – time, inventory, movement, to 9 kilometers per day. Proper layouts
stream infections by 76 percent, reducing waiting, overproduction, overprocessing minimize this, along with reducing
patient deaths from these problems by and defects – plus wasted talent) provide transportation time for patients,
26 Industrial Management
specimens and other hospital staff. but on the same trip. Another example of lean and is a key for good quality.
Wasted motion, which can refer to involves labs that use more of the hypo- Without standardization, all of your
workplace ergonomics, also applies in osmotic swelling solution when evalu- nurses, technicians, physicians and
hospitals. If tools and instruments aren’t ating the sperm membrane to assess administrative staff will perform tasks
handy, people will move here and there sperm vitality. The extra use doesn’t make differently. This makes tracking the
searching for them. a difference and is just waste. And some source of errors difficult. Without
Medical overproduction usually labs leave sperm in the solution longer standardization, the traditional gemba
involves unnecessary tests and checkups. than necessary, while less than a minute walk – leaders examining where the
Overproducing information that is not is more than sufficient. Overprocessing work is done and analyzing processes –
useful or won’t be used is a waste that In her book Value Stream Mapping for is replete in is pointless.
can delay treatment and add costs. HealthCare Made Easy, Cindy Jimmerson medical care, The standard should involve the work
Hospitals also face the traditional showed how mapping the process particularly with elements, the work sequence, the tools,
trade-off between keeping limited can tackle wastes in patient treatment patients who equipment and material needed and the
inventory without running out of processes. The process of patient have amount of time it should take. Without
necessary supplies. Lean encourages treatment starts when the patient to describe those elements, workers will have no way
having the right supplies and inventory feels symptoms, continues with the their symptoms of knowing whether they have improved.
on hand to ensure the right patient care patient receiving care and ends with multiple times. Doing the job differently every time
can be delivered on time. A lean tool like bill payment. The process may include makes consistent quality and produc-
kanban can ensure the right supplies are making appointments to meet doctors, tivity impossible.
available in the right place at the right screenings and analysis, delivering test A lack of standards in processes can
time. results and receiving treatment, along lead to miserable results. CBC News
Overprocessing is replete in medical with follow-ups until full cure. reported on Northern Health, a hospital
care, particularly with patients who have in England, that performed procedures
to describe their symptoms multiple Standardization is the foundation on 10,000 patients over three years with
times – not just in follow-up visits, Standardized work is a foundation improperly cleaned endoscopes.
january/february 2018 27
 Proper standardization removes Standardizing common daily tasks wrong uterus – devastating errors that
wastes, maintains quality, controls frees up healthcare professionals can result in babies intended for other
variation and improves productivity. who can use that time to focus on couples being born by someone else.
Improper standardization, however, value-added work, proactively solving Such calamities, experts insist, are
can amplify problems. Forms that uncommon problems and daily rare. The body representing Canada’s
patients must fill out and sign often are a pop-ups. largely for-profit fertility industry says it
frustrating holdup, so a standardization is unaware of any cases of “misdirected”
process that adds to these forms will not Standards guard against calamity embryos, but a smattering of reports of
improve things. Industrial and systems engineers are in-vitro fertilization (IVF) mix-ups in
Great hospitals in the United States often reminded that patients aren’t the United States and elsewhere have
and Japan have introduced standards widgets, so manufacturing principles led to emotionally wrought battles to
through all levels, including their CEOs, might not always apply. And it’s true determine legal parentage and custody.
presidents and directors. While senior that standardization may not be done In 1999, a New York State woman of
leaders likely will have less of their time for all processes. But standardization Italian descent gave birth to twin boys
covered by standardized work, many can benefit many processes that affect – one white, the other black. Reportedly,
organizations have a standard for what patient safety. Hospitals should have the clinic hadn’t properly flushed the
leaders and managers should look for common processes for hand washing pipette between transfers. In 2015, a
in gemba walks. A standardized work and hygiene, preparation steps for woman in Poland gave birth to another
process should be used to train the new cardiac surgery, labeling patient Waste … woman’s child after her husband’s
staff and educate patients. specimens, administering medication, will delay sperm was mistakenly used to fertilize
These guidelines can help your communicating with patients and patient someone else’s egg.
healthcare center write the right cleaning and disinfecting patient rooms. discharge and Many fertility centers use barcodes
standards: Examples of standardization keep rooms made from polysilicon, the same
problems abound in healthcare. And from opening material used in glass, to prevent
1. Don’t rely on previous time studies none are more tragic than those that up for new such IVF mix-ups. Each tag is about
recorded at the engineering office. affect life at its beginning. patients. one-tenth the width of a human egg
2. Eliminate any wasted motion and Take the case of one hospital that and can be marked with patterns repre-
waiting times. Don’t include any performs intracytoplasmic sperm injec- senting an eight-digit binary code,
walking time in the work elements. tions (ICSI). On the day the clinic providing 256 possible combinations.
Don’t include any non-value-added retrieves the woman’s eggs, the couple To attach these barcodes to eggs,
work. has to wait for three hours in the patient clinics use a protein that binds the
3. Measure the time of each work room to sign forms related to embryo carbohydrates on the cell’s outer surface.
element separately. Don’t include cryopreservation. While the routine Following a standard process to check
only the total time of the job. form was necessary, the waiting time is that the right egg is being used, the
4. Standards should be an output unacceptable. If the hospital does 20 barcode is read using a microscope
from process mapping. Human ICSI operations per day, this is 60 hours before the IVF procedure. The tag
time usually should be separated of waste that will delay patient discharge doesn’t affect the egg or the embryo and
from the process time. and keep rooms from opening up for is shed by the embryo when implanted
5. Allow people to share their ideas for new patients. into the womb.
improving their work. Standardization also can benefit the Communication can be another
6. Use auditing to ensure people are process of labeling patient specimens. key standard. Adam International
working to the standard. If the This is a critical process where incorrect Hospital is a fertility center in Egypt
standard is not being followed, labeling can lead to catastrophe. that standardizes what doctors and
leaders must ask why. Leaders A recent article published by The assistants say in the operating room
should work with employees to American Society of Reproductive before surgery starts. This has had a
improve standards and remove any Medicine maintained that fertility clinics remarkable result on patients’ satis-
obstacle. have an ethical obligation to disclose faction and morale. In many cases,
7. Standardization should be a part of mistakes that could result in babies educating patients on their medications
any improvement efforts to achieve born with a “different genetic parentage is very necessary. It usually includes how
the organization’s vision and goals. than intended.” Incorrect labeling to take the dosage and the possible side
Forcing people to follow a standard could lead to inseminating a woman effects, and proper communication is
because management needs to with the wrong sperm, combining the vital.
make things look better is not what wrong sperm with the wrong eggs or Communicating efficiently with
adds value to the customer. transferring the wrong embryos to the patients and families before surgery
28 Industrial Management
also adds value to healthcare services. Likewise, adding more value to patients value in patient care. This short-term
Acknowledge the person by name, is a long-term investment. Short-term financial thinking cost the fertility center
introduce yourself, discuss the duration cost reduction thinking can sabotage much more than what it saved via batch
of stay, explain what you are doing and, patient morale and satisfaction and delay processing of the sperm DNA test.
finally, thank them. treatment.
Some surgical processes that are For example, for the purpose of The proper lean healthcare tools
done without anesthesia require patient economy, some laboratories process While tools help, management methods
education and clear instructions. Take certain tests once every two weeks. But and philosophical concepts can assist
the IVF embryo transfer operation. this can delay in ways that will cost the your organization in choosing the
The gynecologist should describe the hospital far more than any short-term right tools for your situation. Beyond
process to the patient and give her savings. One couple had worked for standardization, the most common lean
clear instructions. For example, female three years but still had not achieved tools used in healthcare are 5S, visual-
patients must lie on their back for one pregnancy. Before doing an ICSI ization and kanban.
hour after this procedure. She cannot procedure, a fertility clinic specialist 5S (sort, set in order, shine,
move and must keep her head in a flat wanted to assess the sperms’ DNA standardize, sustain) is a method of
position. And for the following few days, fragmentation to determine their fertil- creating a clean, well-organized and safe
she must take several precautions and ization ability, a dispersion test that workplace free of clutter and wasted
follow a particular diet. should take labs no more than two days. Short-term motion. 5S is about eliminating waste,
Failure to adhere to these instructions But since the lab always waited until cost reduction not just making the place look nice.
could cause the embryo implantation it had several specimens to run the test thinking can Sort eliminates items that haven’t been
to fail. once or twice a month, the laboratory sabotage used for a while. Set in order organizes
took five weeks to deliver the results. patient what is left in a way that will make it
The proper lean mindset On top of that, after the results were in, morale and easier to find tools and materials. A good
The proper mindset is important for a the doctor had to prescribe antioxidant satisfaction example of standardization in this arena
lean culture to flourish. medicines for three months and repeat and delay is shadow boards. These boards outline
As Liker described in The Toyota Way, the test. That totals five-and-a-half treatment. tools so it’s easy to see which instru-
one Toyota management principle is to months of waiting time for a process that ments are missing, insuring that every
“base your management decision on should take three months and four days. tool has a place and is returned after use.
long-term financial benefit even at the The frustrated couple decided to go Shine is about cleaning, which is all
expense of the short-term financial gain.” to another place that provided more about infection control in healthcare.
january/february 2018 29
Sustain audits to make sure things don’t Lean principles can be combined with usually aspirin and heparin drugs.
slip back. other approaches like total production Testing costs about $500 and can save
Visual management is a problem- maintenance. TPM helps ensure that couples who choose IVF a lot of time
solving and prevention technique for machines and instruments are working and heartbreak. If a couple decides to
reducing wastes. Examples include labels optimally. For instance, the ultrasonog- perform the additional tests, which
that warn about “Caution, hot contents” raphy machine is a critical instrument cost $500, they will be able to reduce
or “Warning! Risk of injury.” Labeling in gynecology clinics, where a failing the risk of failures instead of waiting
specimens, as noted above, is a good or broken machine will delay patient until it happens and lose all the effort
example of visual control to prevent treatment. and money they spent in IVF. Doctors
errors. should have a standardized process
Many hospitals use visual Analyzing failure for what questions they ask patients
management to identify the status of prevents problems before treatment starts. Some diseases,
patients and their need to facilitate A main goal of lean is to prevent including thrombophilia, can be genetic,
real-time decision-making. Tracking problems before they happen, thus so questions about historical family
boards identify which rooms are open improving patient care. While analyzing diseases should be on the list.
and let families know where their loved the root cause of problems can prevent Understand that hospitals shouldn’t
ones are. Some hospitals have automated their reoccurrence, analyzing failure overproduce diagnostics and tests and
this process and use large digital screens possibilities can prevent catastrophes. perform unnecessary checkups. That
and software for managing the system. A statistical quality tool like failure would be considered waste. But when
Kanban is a method that often mode effect analysis (FMEA) can identify there can be a high-risk result from not
controls inventory buffers. The system critical processes and the consequence testing, the risk should be estimated and
yields fewer stock-outs and better of failure. Then it’s up to management testing considered, as in the IVF-throm-
material availability than other inventory to use the best method to prevent those bophilia case.
management systems. In hospitals, failures from occurring.
kanban manages medical supplies, Many doctors track the causes of Lean can bring positive
drugs, office supplies, linen and other failure after they occur. While some change to healthcare
commodities. failures can harm patients, others crush Healthcare professionals should not
Kanban started to appear in healthcare morale and cost money. use lean approaches to seek direct cost
in the late 1980s through the devel- As noted above, pregnancy is a great reduction. Their main focus should be
opment of a two-bin system for medical example. When natural pregnancy on adding more value to patients and
supplies. When one compartment of is not possible, the next best choice improving quality – the cost improve-
supplies is empty, the nurses use the is IVF treatment, which is complex ments will come indirectly.
second (or backup compartment) and and expensive, averaging $15,000 for People It’s very clear that standardized work
identify that a bin has been emptied. each fresh cycle in the United States. aren’t is the foundation of healthcare quality.
Material handlers normally check Insurance often doesn’t cover the resistant to But when applying lean, remember
nursing unit supplies on a fixed procedure, and sometimes it can be change, but that we don’t standardize processes for
schedule. The handlers scan the kanban difficult to find an egg donor. The success they resist the sake of standardization. We do it
cards and transfer the requests to the rate, already low at 50 percent, also being for consistent quality and productivity.
material management’s information depends on the woman’s age. changed. People shouldn’t be forced to follow a
system. For items stored in the central All of these factors can make a failure standard without asking their input.
warehouse, the information system after treatment emotionally devastating People aren’t machines, and lean
generates a pick list. to the couples involved. This makes the practitioners always should remember
For direct purchases (items sourced results shared in the paper “Successful that respect for people is an important
externally), the system transmits a Pregnancy Outcome in a Case of part of lean.
requisition to suppliers. Finally, material Protein S Deficiency” by D.M. Lalan, People aren’t resistant to change,
handlers deliver medical supplies directly M.J. Jassawalla and S.A. Bhalerao inter- but they resist being changed, and lean
into the empty bins, ensuring stock esting to people with such problems. tools won’t work without the correct
rotation in each unit. The authors found that one out of every culture.
Kanban systems save hospitals 500 to 3,000 women lose pregnancy But it should be much easier to involve
money. One medical center in Egypt due to protein S deficiency, which is an healthcare workers in a lean transfor-
reduced inventory holding value from $3 inherited form of thrombophilia. mation, because unlike other sectors,
million to less than $800,000. Another Treatment for thrombophilia during people working in the medical industry
reduced unplanned calls for materials by pregnancy is easy and involves taking are intrinsically motivated by the desire
50 percent. the correct medication and injections, to help people and save lives. v
30 Industrial Management
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