Lean Healthcare Overview

Lean 101Opportunities and

Challenges in Healthcare

Roper & Associates Inc.

2Roper & Associates Inc.

Agenda

• Lean healthcare – what is it?• Where and how does it apply?• Why is it so hard to succeed?• How do you get started?• Summary and conclusions• Appendix


Lean Healthcare – what is it?• Lean healthcare is:

– An integrated philosophy, set of principles and tools– Based on principles of the Toyota Production System and

focused on understanding and eliminating process “waste” by:• Stabilizing / leveling work load• Standardizing how work is performed• Identifying and solving problems daily• Engaging everyone in process improvement• Valuing a common way of performing work• Focusing on system effectiveness, rather than functional efficiency

• Waste and value– Value is judged only by the customer (patient)– Value adding activities in a process change the form, fit or

function of the product or service– Activities that do not add value are waste; all they add is cost


Lean Healthcare – what is it?• As in manufacturing, lean healthcare goes by many

names (yet the underlying principles are all the same):– Perfecting Patient Care – Pittsburgh Regional Health Initiative– Continuous Performance Improvement – Children’s Hospital and

Regional Medical Center, Seattle– ThedaCare Improvement System - ThedaCare, Appleton, WI

• As in manufacturing, lean healthcare is no longer “new”– Many sites well down the learning curve (5+ years into their

transformation) and “learning” the same lessons manufacturers have learned

– 335 lean healthcare references on Lean Enterprise Institute (LEI) website, covering wide range of implementation sites

• Of all the improvement concepts embraced by manufacturers in the last 35 years, lean has “stuck” the longest and is still evolving – will healthcare be the same?


Lean Healthcare – what is it?

• Lean healthcare isn’t:– Just a set of tools like 5S, standard work, value

stream maps, kaizen events, A3 problem solving, mistake proofing, etc.

– Something that succeeds “bottom up,” without leadership understanding and support

– Something that can be precisely planned at the outset, it must evolve in any organization

– Something that anyone can understand without hands on experience


Lean Healthcare – what is it?True lean is about principles, not tools:1. Directly observe work as actions (steps taken), connections

(how customer/supplier pairs function) and flows (paths and rates for material, information and people)

2. Engage in systematic waste elimination – understand waste and value, and how to identify and reduce or eliminate waste

3. Establish high agreement on what (goals) and how (process)– Value a common way or process, with low ambiguity, more

than you value your own way4. Encourage systematic problem solving by using a standard

system to expose and solve problems5. Create a learning organization – experiment, follow PDCA

cycle, reflect, manage comfort and fear zones and provide the time to do it

* - Hitchhiker’s Guide to Lean


Where and how does it apply?• Lean healthcare principles can provide:

– Point solutions to reduce or eliminate specific, often simple, problems– Building blocks of a complex, system level (value stream) improvement

• Some typical examples

IMPROVEMENT EXAMPLES IMPACT LEAN TOOL APPLIED

REDUCING TIME WASTED WHEEL CHAIRS MORE NURSING TIME AVAILABLE 5S / WORK PLACE ORGANIZATION, STANDARDLOOKING FOR THINGS INFORMATION MORE HOUSEKEEPING TIME AVAILABLE WORK

EQUIPMENT REDUCED TURNOVERSUPPLIES AND KITS BETTER SCHEDULE ADHERENCE

REDUCED TURNAROUND TIME LABS FASTER TEST RESULTS 5S, VALUE STREAM MAPPING,PHARMACIES FASTER MEDICATION DELIVERY SET UP REDUCTION

OPERATING ROOMS REDUCED OPERATING ROOM DOWNTIMEPATIENT ROOMS REDUCED BED / ROOM DOWNTIME

REDUCED DELAYS / TOTAL REGISTRATION LESS PATIENT WAITING VALUE STREAM MAPPING, STANDARD WORK,PROCESS LEAD TIME OPERATING ROOMS BETTER SCHEDULE PERFORMANCE LOAD LEVELING

TRANSPORTATION LESS DOCTOR WAITING

REDUCED ERRORS INFECTIONS REDUCED INFECTION RATES STANDARD WORK, 5S, MISTAKE PROOFINGPHARMACY ISSUES REDUCED FALL RATES

MORE EFFECTIVE HAND OFFS PATIENTS MORE PATIENT TIME FOR NURSES & OTHERS STANDARD WORK, 5S, MISTAKE PROOFINGINFORMATION IMPROVED PATIENT SAFETY


Where and how does it apply?Organize storage areas to reduce time spent searching for supplies or equipment

Organize lab samples to simplify processing and reduce errors

5S – a place for everything and everything in its place, easy to

access and ready to use

Before – samples arrive haphazardly in plastic bags and pink buckets

After – samples and paperwork arrive together in well organized tray


Where and how does it apply?

Before:• Work area cluttered and

potentially dangerous• No standard process evident• Not designed for flow

After:• Work area organized; contains

100% of what is needed to do the work (and nothing that isn’t needed)

• U-shaped work area (cell) designed for continuous flow

Organize lab to improve processing efficiency (response time and work time)

Lean tools applied - 5S, standard work, cell design


Where and how does it apply?• A more complex case - reducing Central Line Infections

– Allegheny General Hospital, 2004, supported by PRHI / PPC, physician lead effort

– Goal – eliminate CLIs in 2 ICUs, in 90 days• Approach:

1. Clearly define the current condition• Chart review of 1700 patients for 2002 – 2003 to set the baseline

– Standard metric - 5.1 infections / 1000 line days (meant what?)» Translation – in prior year 37 patients got 49 infections, 19 died

– Also had 10.5 infections / 1000 line days for femoral lines• Decided to focus on all infections, with a goal of zero

2. Observe the actual work in detail; 40+ hours of observation revealed significant variation in use of standard protocol by nurses and doctors

3. Define, train and communicate standard protocol (standard work) for central line insertion and maintenance


Where and how does it apply?4. Use real time data and act on it immediately to solve

problems one by one, as close to the time and place of occurrence as possible• Respond to any identified infection within 6 hours• Identify “root cause” of the infection – most often one or

more steps of standard protocol breached• Refine and communicate standard protocol based on

learning• Institute necessary behavioral changes; nurses given right

and responsibility to stop a procedure if protocol is not being followed

5. Provide continuous training for staff, especially new staff



• Result - number of infections dramatically reduced and no deaths, despite:– More line insertions– More severe cases on average



• A more complex case – improving ED throughput– St. Mary’s Health Care, Grand Rapids, MI

• 2005 process characteristics:– ED largest department in hospital– Average door to discharge - 4.9 hours

• 20% discharged in < 2 hours

– ED staff turnover high and patient satisfaction low• Process improvement objective:

– Door to discharge < 2 hours for 80% of patients discharged


Where and how does it apply?• Approach – use kaizen event to analyze how to apply

lean principles to achieve improvement objectives– 28 of 150 ED staff participated– Mapped the ED process flow from registration to discharge– Identified “wastes” in the process to reduce or eliminate


What they did• Identified specific sub-process performance objectives necessary to

achieve the “big objective” – 2 hour process for 80% - and a plan to achieve them:– Triage in 10 minutes– Patient prep in 10 minutes– Evaluation / orders / diagnostics collected in 20 minutes– All results in < 1 hour– Discharge time of 20 minutes

• Assigned incoming patients to 1 of 3 groups for processing – discharge, admit and ?– Assigned best charge nurses to triage and standardized the triage

process• Reorganized ED into service PODs to reduce travel and maintain a

focus on serving patients (to move them through the process):– Initially for nurses only; eventually for doctors too– All needed supplies and routine equipment located in the PODs

• Focused on point based improvements to:– Reduce registration time and improve information quality– Reduce discharge time– Reduce lab TAT


What they got

• Financial benefit for the hospital from increased patient volume, fewer diversions, due to higher productivity and capacity


Why is it so hard to succeed?

• To succeed with lean, the organizational culture must change– Focus on defining robust processes, then sustaining and continuously

improving them– Organization must “trust” process improvement to deliver results and

support it as a way of doing business– Managers at all levels must become leaders and coaches (always an

issue); process discipline and follow up are critical– Employees at all levels must engage in process improvement (not

usually an issue)– It’s not glamorous work; head down in the trenches, improving

processes (it’s sometimes hard to step back and see the big picture)– Setting, communicating and achieving performance improvement

objectives is a never ending process– You understand why these issues are critical by doing it (lean); there is

no other way that has shown consistent success• But, once you “get it” everything becomes a lean opportunity


Why is it so hard to succeed?

• What makes healthcare more difficult:– Overcoming the “people aren’t widgets” mentality

(they aren’t, but they still “flow” through your processes)

– Size and complexity of healthcare facilities– “Work around” culture– Getting the doctors on board is key, but also very

difficult in most situations; financial, stature and time issues get in the way


Why is it so hard to succeed?• Common problems:

– Underestimating the leadership commitment and time required to succeed

– Impatience (project vs. journey); change is slow and can be extremely frustrating

– Not dedicating resources and time to lean efforts, including some experienced help for training and support

– Focusing only on tools, not culture change (behaviors)– Many people will resist it and the organization will try to kill it– It’s often hard to tell how its going; it may appear to be failing

right up to the point where it really takes off– Eventually, not connecting lean to the business case


How do you get started?

• Lean success depends on recognizing and following seven key principles:– Three integrated system elements must be in place

• A lean operating system• Sustained by a lean management system• Supported by appropriate organizational mindsets and

behaviors– Four implementation strategies must be followed:

• Implement by value stream or “model line”• Deploy in “generational waves”• Implement to achieve specific, measurable objectives• Support with a robust change management structure



• Mark Graban – ThedaCare Center for Healthcare Value– “To impact the big picture you have to start with small steps”– Start in a department or patient pathway (value stream) that has

a significant improvement need

• Keep the scope small, but implement as much of a full lean system as possible, then use the area as an organizational learning lab

• Dramatic improvement will help get people’s attention and provide the credibility to use the improved area as a learning model for other areas


How do you get started?• George Koenigsaecker, business general

manager, lean leader and author– Find a change agent– Get the knowledge– Find a lever - seize a crisis or create one– Forget grand strategy initially– Map your value streams– Begin as soon as possible with an important and

visible activity– Demand immediate results– As soon as you’ve got momentum, expand your

scope


How do you get started? • Lean implementation is a multi-year learning process that takes time,

organizational discipline and consistent leadership• Most organization lack the leadership continuity and organizational

focus to get “over the hump” to the integrate, sustain and continuous improvement phases

YEAR

Executive learning, alignment and commitment at this stage is critical



• Decide whether to start (Why should your organization be doing this?) :– What critical internal and external improvement needs do you

have?– Do you have a program or set of initiatives capable of satisfying

those needs?– If not, could lean fill the gap?

• In manufacturing (and healthcare) lean improves quality, cost, delivery and asset productivity; this impacts:– Company financial performance – profitability and investment

requirement– Market competitive position – service consistency and flexibility,

product quality and cost


Summary and Conclusions

• The application of lean principles to improve operational and financial performance has been proven in manufacturing, administrative and healthcare environments

• Though healthcare application is the most recent, it is maturing rapidly with implementation timelines and benefits that mirror other environments

• Lean application increases process capacity; in healthcare this is manifested as:– Increased organizational capacity to serve patient needs –

nurses, doctors, etc.– Reduced errors and service delays– Increased process capacity – labs, pharmacies, operating

rooms, etc.– Improved employee morale and patient satisfaction


Summary and Conclusions

• There are many organizations to learn from and lots of people eager to provide help

• Like any important effort, there is never a “right” time to start

• If you have no lean experience or understanding you are not alone, most people don’t

• You only “get lean” by doing it; don’t be afraid to start and expect to commit significant time and organizational energy to it

• For those who succeed, the payoff is well worth the effort


Appendix

• Support resources• References


What resources exist to help?

• ThedaCare Center for Healthcare Value– A new branch of the Lean Enterprise Institute (LEI)– LEI is a non-profit training organization dedicated to global

expansion of lean thinking• Healthcare Performance Partners, Nashville, TN

– HPP is a lean healthcare consulting firm– Lean Healthcare West is an affiliate of HPP

• Pittsburgh Regional Health Initiative (PRHI)– PRHI is a lean healthcare training organization within the Jewish

Healthcare Foundation of Pittsburgh– PRHI provides training and consulting support for their

Perfecting Patient Care model of lean healthcare– The Pittsburgh Way was written by Naida Grunden of PRHI

• Belmont University, Nashville, TN provides lean healthcare training in cooperation with PRHI and HPP


What resources exist to help?

• Lean Enterprise Institute (www.lean.org ) – Healthcare section of Knowledge Center contains:– 335 references to lean healthcare– Includes a Google map showing 135 lean healthcare

sites in North America (page 2 of healthcare section)

http://www.lean.org/


References

• The following book and presentation were used for examples and information in this presentation:– The Pittsburgh Way to Efficient Healthcare, Naida

Grunden, Productivity Press– Utilizing Lean Principles to Improve Patient Flow in

the ED, AME presentation by St. Mary’s Health Care, November 2006

Health & Medicine

Lean Healthcare Overview