| Lean production (Lean) is a type of quality | | | | Health care organizations typically spend a larger |
| improvement methodology which has been | | | | percentage of operating expenses on overhead and |
| implemented in many industries. Its principles and | | | | labor costs. This can account for 50 percent of the |
| practices also have been applied to health care | | | | operating costs while inventory is in the range of 2 |
| organizations with success. This has been | | | | percent (Caldwell, 2005). Understanding waste in |
| accomplished with refinement for the nuances of | | | | throughput entails a comprehension of the relationships |
| health care. Lean is a process management philosophy | | | | between process variables and costs. Costs are not |
| which has its roots in manufacturing and technology. It | | | | causes of waste but are indicators of interrelationships |
| was developed as part of the Toyota Production | | | | between processes. While the ultimate goal of most |
| System for the process assembly of automobiles | | | | Lean implementations is to recover costs as tangible |
| (Toyota Motor Corporation, 2009). The Toyota | | | | benefits, eliminating costs without fully understanding |
| System is comprehensive and spans a large number | | | | processes is problematic. Looking at the types of cost |
| of methods and practices. It was initially influenced by | | | | recovery is essential to determining an action plan. |
| the work of W. Edwards Deming and Henry Ford and | | | | Solution: Cost Recovery |
| was also inspired by innovation in the American | | | | The ultimate goal of most Lean implementations is to |
| grocery store industry of the 1950s (Keller, 2006). This | | | | attain a tangible benefit, often in the form of a cost |
| is reflected in the Just-in-Time philosophy of | | | | recovery. However, not all process improvement |
| productivity improvement, which emphasizes producing | | | | opportunities will result in immediate returns. The actual |
| quality products efficiently through the complete | | | | realization of a benefit depends on the nature of the |
| elimination of waste, inconsistencies, and unreasonable | | | | improvement as well as the additional steps that |
| requirements (Toyota Motor Corporation, 2009). | | | | management takes to achieve it. Caldwell (2005) cites |
| Though the Lean methodology was initially developed | | | | three types of cost recovery through the elimination of |
| as part of an overall system focusing on the | | | | waste: Type 1, Type 2, and Type 3. In a Type 1 |
| production of automobiles, its principles also have been | | | | situation the process throughput improvement will yield |
| adapted for health care. As certain case studies | | | | a direct cost recovery. For example, a process |
| indicate, Lean thinking and tools have been successfully | | | | improvement that reduces length of patient stay would |
| applied to specific health care settings. The scope and | | | | recover costs in the form of reduced resources |
| value of Lean production within this field will be | | | | expended. In a Type 2 situation, the process |
| explored in this paper. | | | | improvement saves time but does not result in cost |
| Significance:Value | | | | recovery without additional hours worked per unit of |
| A significant component of Lean is the concept of | | | | service. A provider may spend less time per patient |
| value: the theoretical concept of value, the | | | | because of reduced length of stay but scheduling will |
| measurement of value, and the tangible processes | | | | need to be adjusted in order to capitalize on the |
| behind delivering value. Lean is unique in that it | | | | benefit to workflow. Lastly, Type 3 yields savings in |
| accounts for the reduction of waste in order to | | | | the form of immediate optimization of capacity. In this |
| achieve both real and potential value. Recovering this | | | | situation a process improvement in an emergency |
| value can present itself in the form of saved costs or | | | | room, for example, may allow a provider to see more |
| other tangibles. Lean thinking dictates that the | | | | patients in the same staffed time without additional |
| expenditure of resources for any purpose other than | | | | action taken by management. This is similar to a Type |
| delivering value to the customer is considered to be | | | | 2 recovery but with no changes to scheduling. This |
| wasteful. The reduced expenditure of time, money, | | | | can occur if the provider is willing to see more patients |
| and resources is thought to bring additional bottom-line | | | | per unit of time and sufficient patient volume exists to |
| benefit to the customer. The customer-centric focus | | | | achieve capacity. Maximum velocity is achieved |
| of Lean thinking is especially relevant to health care. | | | | without additional action needed to be carried out by |
| Broader levels of patient/customer satisfaction are | | | | management. These examples show that throughput |
| constantly being sought. This mode of thinking has | | | | improvement may not achieve an immediate benefit |
| been brought on by increased competition among | | | | without other factors. It also brings to light the fact that |
| organizations and the need to differentiate services. It | | | | throughput improvement may yield different benefits |
| is recognized that providing complete customer | | | | such as recovered costs, time saved, or increased |
| satisfaction can be vastly beneficial to health care | | | | revenues. Regardless of the actual benefit achieved |
| organizations. Customer satisfaction can be an equally | | | | and the way that it is realized, the ultimate outcome |
| important measure of an organization's performance | | | | must increase bottom-line value and satisfaction to |
| as the delivery of quality health outcomes. This is a | | | | customers in some way. |
| factor which is exemplified in Noriaki Kano's model. | | | | Examples of Lean implementation in Healthcare |
| Lean thinking dictates that processes and methods | | | | The study of actual Lean implementations in health |
| must be efficiently optimized with the needs of | | | | care is essential to understanding their application. One |
| customers in mind in order for organizations to be fully | | | | example of a successful implementation is outlined by |
| effective. | | | | Fairbanks (2007) at a medical center in Vermont. This |
| Problem Addressed: Waste | | | | implementation dramatically improved overall |
| Lean focuses on the maximization of process velocity | | | | throughput processes within the organization. An |
| through the reduction of waste. It provides tools for | | | | implementation team was assembled and delved into |
| analyzing process flow and delay times at each | | | | all steps of the processes they were analyzing in |
| activity in a process. The focal point is the separation | | | | order to determine the sources of waste. They utilized |
| of "value-added" from "non-value-added" work. This is | | | | various Lean steps and methodologies to conduct |
| complemented by tools which aide in the identification | | | | root-cause analyses and prioritize process |
| and elimination of root causes of non-valued activities. | | | | improvements. The team measured time involved, |
| The primary problem addressed by Lean is waste, | | | | identified activities, and made rapid improvements |
| which can affect value in a number of ways. It may | | | | through the elimination of non value-added activities. A |
| result in lower quality products, higher costs, less | | | | large part of their improvements involved the |
| favorable customer experiences, excessive time or | | | | elimination of redundancy. The topic of redundancy |
| effort expended to complete goals, or fewer | | | | shows the importance of analyzing all processes, even |
| resources available for innovation which could provide | | | | those which are perceived to contribute to customer |
| potential value at a future date. Waste can be found in | | | | value. Even though a particular function may provide |
| people, processes, tangibles, and other areas. | | | | value in an organization it is possible that a redundant |
| Eliminating waste through the lens of Lean production | | | | function may exist which can be eliminated. In another |
| can help to achieve the goals of health care | | | | case example Lean methodology was used to |
| organizations. There are eight generally identifiable | | | | streamline the physical space and inventory areas of a |
| centers of waste: overproduction, waiting (time on | | | | Denver-area hospital (Gabow, Albert, Kaufman, Wilson, |
| hand), unnecessary transport or conveyance, | | | | & Eisert, 2008). The implementation team utilized |
| over-processing or incorrect processing, excess | | | | the 5-S approach to organize physical work spaces |
| inventory, unnecessary human movement, defects, | | | | within the hospital. 5-S is a Lean improvement which |
| and unused employee creativity (United States Army, | | | | incorporates visualization management to organize |
| 2009). There are variations on these categories of | | | | objects and supplies. The five Ss stand for sort, set in |
| waste depending on the setting or industry. For the | | | | order, shine, standardize, and sustain. These steps |
| purpose of health care Caldwell (2005) slightly refines | | | | involve tasks ranging from simple clean-up and |
| these measures into seven categories of waste. | | | | organization to the implementation of detailed visual |
| These consist of "in-quality/out-of-quality staffing or | | | | controls. In a 5-S environment there is "a place for |
| overcapacity, overcorrection, over processing, excess | | | | everything and everything in its place, when you need |
| inventory, waiting, motion of patients or staff, and | | | | it (Lean Innovations, 2003)." The Denver hospital used |
| material and information movement (Caldwell, 2005, p. | | | | this approach in a series of projects focusing on |
| 46)." Regardless of the differences in terminologies | | | | individual offices, nursing stations, entire laboratories, |
| used, there are common centers of waste in health | | | | and financial services departments. These spaces |
| care which can be targeted for elimination. These can | | | | were reorganized to achieve optimal work flow and |
| be identified through Lean processes which focus on | | | | good space management. The successful outcomes |
| root cause analysis. | | | | included reclaimed physical work space, improved lab |
| Process: Root Cause Analysis | | | | turnaround time, reduced time in locating equipment, |
| A crucial process in Lean is the identification of waste | | | | and better processes which could improve patient |
| through root cause analysis. Root cause analysis in | | | | care (Gabow et al, 2008). The 5-s method is an |
| Lean involves a method called 5-Whys (Toyota | | | | excellent first step in implementing Lean programs in a |
| Manufacturing Kentucky, 2003). This method rapidly | | | | health care organization. Improvement of physical work |
| identifies root causes and aides in determining the | | | | space can positively affect mindset and mental |
| relationship between multiple root causes. It can be | | | | perception of work. Another case example of a |
| learned quickly and does not require statistical analysis. | | | | successful 5-S implementation involves a rural health |
| This method is especially effective for an | | | | clinic in Georgia. Lean techniques were used in this |
| implementation team in the initial stages of problem | | | | organization to resolve problems with bottlenecks, |
| exploration. The application of this strategy involves | | | | turnaround times, customer satisfaction, and |
| asking a series of why-related questions to drill down | | | | overworked nurses (Cross, 2009). 5-S is one of many |
| into a problem area. Asking progressive questions | | | | Lean tools which can provide immediate benefit. |
| about a perceived difficulty forces team members to | | | | Conclusion |
| think critically about the actual sources of waste and | | | | Lean is a multifaceted approach to quality |
| inefficiency. It is suggested that at least five questions | | | | improvement which has tangible benefits to health |
| (5-Whys) are posed to arrive at the root cause, | | | | care organizations. There are aspects which focus on |
| though a root cause may be discovered in more or | | | | reducing non value-added work and waste to achieve |
| less inquires. | | | | value in various ways. Successfully implementing Lean |
| The following is an example of a 5-Whys exercise | | | | in health care depends on the setting involved and the |
| used in a hypothetical hospital setting: | | | | motivation of management and teams. Health care |
| (Q1) Why are patients being diverted to neighboring | | | | encompasses a wide range of organizations and each |
| hospitals? | | | | has unique characteristics which must be considered in |
| (A1) Because wait times for our hospital are | | | | light of Lean processes. Important considerations in |
| exceeding industry norms. | | | | implementing lean in any environment can be reduced |
| (Q2) Why are our wait times exceeding industry | | | | to a few key points: Understanding the concept of |
| norms? | | | | value Understanding waste and its sources Learning |
| (A2) Because patient volume is exceeding capacity. | | | | how to determine and analyze root causes Prioritizing |
| (Q3) Why is patient volume exceeding capacity? | | | | multiple root causes Devising methods to eliminate |
| (A3) Because not enough hospital beds are available. | | | | waste Determining ways to recover costs or achieve |
| (Q4) Why are not enough hospital beds available? | | | | benefits Analyzing effectiveness and repeating steps |
| (A4) Because hospital patients are not being | | | | if necessary In addition, it is important to note that |
| discharged efficiently. | | | | eliminating waste through a Lean process may not |
| (Q5) Why are hospital patients not being discharged | | | | immediately result in tangible benefit. Management |
| efficiently? | | | | must thoroughly analyze action plans and make |
| (A5) Because ER staff is not following best practices | | | | adjustments based on actual outcomes. Additional |
| for proper discharge. | | | | steps may need to be taken following initial process |
| In this example, waste in the throughput process | | | | improvements. This is especially relevant in health care |
| comes from incorrect processing. Once hospital | | | | where process throughput improvement and staffing |
| management determines the root cause they can | | | | are areas which are commonly targeted. These areas |
| implement further training, ensure compliance with | | | | may involve more challenges when trying to extract |
| existing standards, or eliminate other barriers. In this | | | | benefit. Freeing time for providers cannot always be |
| case the hospital might consider implementing a training | | | | capitalized upon without other capacity and throughput |
| program to ensure that ER staff is following best | | | | improvements. Scheduling or work flow functions may |
| practices for patient discharge. The hospital might also | | | | need to be overhauled in order for providers to |
| conduct additional 5-Whys analyses to uncover other | | | | increase overall process velocity and maximize value |
| problem areas. Once root causes of waste are | | | | per unit for time. It is also crucial to realize that humans |
| uncovered, the elimination of waste or other related | | | | are not machines. Theoretical methods of quality |
| action plans can be executed. | | | | improvement in Lean may not always be feasible to |
| Sources of waste | | | | achieve at maximum levels. The Lean methodology |
| Sources of waste vary greatly by industry. The | | | | developed by Toyota is very cognizant of respect for |
| majority of waste encountered by health care | | | | people. It is reflective of a collective culture and a |
| organizations occurs in flow and throughput. As a | | | | holistic concept rather than a series of parts or steps. |
| result, Lean implementations in this field are primarily | | | | This is a fact which cannot be overlooked by |
| focused on the elimination of waste in staffing and | | | | management and teams when planning an |
| staff/patient processes. Unlike manufacturing industries | | | | implementation. People perform processes with normal |
| most health care organizations have very little | | | | human variation and improvements must be sensitive, |
| inventory. Thus, some of the Lean concepts related to | | | | appropriate, and sustainable. |
| inventory control are less applicable to health care. | | | | |