Lean Healthcare

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Introduction

The concept called lean management or lean thinking is most commonly

associated with Japanese manufacturing, particularly the Toyota Production System
(TPS). Lean means using less to do more.

Lean thinking is not commonly associated with health care, where waste of time,
money, supplies, and good will is a common problem. But the principles of lean
management can, in fact, work in health care in much the same way they do in other
industries.

This paper contains a methodology of lean healthcare, the history of lean, the types
of waste in healthcare and provides examples, the improvement techniques and
provides examples of health care organisations or hospitals that are successfully
using lean thinking to streamline processes, reduce cost, and improve quality and
timely delivery of products and services.

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What is Lean all about?

An operating philosophy in which the best quality. Cost and delivery of a product or
service is achieved through shortening the production flow by eliminating waste.

A systematic approach in identifying and eliminating waste, or non-value added

activities through continuous improvement by moving the product at the pull of the
costumer in pursuit of perfection. (Lean Enterprise Institute, 2000)

Myths and Misconceptions

Lean is a Japanese Philosophy.

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Concepts and principles that apply only to manufacturing.

Means busting unions and getting rid of people.

Is the magic pill cure for all business and industry problems

Is just a flavour of the month, a passing pad.

Is a grass roots program.

Lean thinking involves five steps to improve a selected process: value, the value
stream, flow, pull, and perfection: (Campbell and James 2009)

Value
Value is the most important concern within the lean thinking paradigm. Each step in
a process should produce value for the customer. The customer, depending on the
process, can be a patient, a physician, or an administrator. If a process does not add
value it must be re-engineered or eliminated.

Value Stream
The value stream is the steps required to complete a process or service (or in
manufacturing, to create a product). Examining the value stream helps to identify
waste within a process.

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Flow
The goal of flow is to eliminate the use of batching and queuing within a process.
Processes that use batches and queues produce multiple wait times and
interruptions.

Pull
Pull has been described as performing work as it is requested or needed by a step in
a value stream. This is the opposite of push technology, where a product can be
created when there is little or no demand. Push processes can lead to large
inventories and related costs to maintain them.

Perfection
A key tenet in lean thinking is that no matter how many times a process is improved,
it can be further enhanced. The idea of perfection rests on the notion of continuous
improvement through incremental change based on outcomes.

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History of Lean

As early as the 16th century during the public wars, King Henry the 3 rd observed
mass-production complex in Italy with the Venetian Arsenal attorney out completely
galley ships hourly, he was astonished at the speed. Standardisation and
interchangeable parts along with the development but very rudimentary production
line were the contributing factors to the systems efficiency. Centuries later in 1799,
Eli Whitney, an American inventor best known for inventing the cotton gin would have
popularised perfect the use of interchangeable parts through his musket
manufacturing business in the early nineteen hundred, Frederick Taylor the father of
scientific management was fascinated finding the best way to perform a task.

Four century man had profound effects in the development of modern lean thinking
and the first was American inventor Henry Ford, he founded the Ford Motor
Company and introduce the automobile change the world the Model T, however for
its contributions to manufacturing stretch beyond gasoline-powered engines, his
development a movie production line and his many philosophies on manufacturing
and efficiency revolutionary.

Taiichi Ohno, the Toyota engineers synthesise the Toyota Production System laying
framework for lean philosophy. Drew upon fords ideas expressed in his 1926
memoir, today and tomorrow improve them been created his own methodologies.

Another great inspiration for Ohno was Sakichi Toyoda, the founder of Toyota
Industries and Toyota Motor Corporations namesake. Sakichi developed important
concepts like five whys or asking why five times to find the true source of the
problem. Jidoka, a Japanese word for Autonomation or intelligent automation. He
was the first to envision a Toyota Production System, though Taiichi Ohno actually
developed and implemented it several years after Sakichi Toyodas death, and
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though he is Toyota Motor Corporations namesake Sakichi never work in the
automobile industry.

In 1910, Sakichi visited the United States in order to tour textile mills, when he saw
how Americans had embraced motorization, he encouraged his son Cachito to
branch of the family textile business into automobiles.

A year before his death Sakichi saw the loom patent to a British company and offer
to chiro the hundred-thousand-pound revenue to fund automobile research. Sakichi
died in 1930, having dedicated his entire life to innovation in making textiles. The
next year, Cachito completed a small prototype of a gasoline engine.

Cachito was the founder of the Toyota Motor Corporation in 1937. He spent much of
his life researching and improving his fathers inventions and ideas. Cachito began
the Just-In-Time philosophy at Toyota and Taiichi Ohno improved it and incorporated
it into a complete system. Taiichi Ohno is credited with the creation of just-in-time
production, better known as the Toyota Production System and Lean Thinking.
Inspiration from great manufacturing leaders, he developed a revolutionary
methodology that enable to become the most efficient automobile maker in the world
and to become a market leader in the global automotive industry despite having
intruded decades behind German and American companies. He also documented
the different types of waste in which the personal war on waste elimination. Ohno
does improvement to the Toyota Production System were born out of the necessity
as Toyota had and uphill battle entering the international auto market place. (Lean
Enterprise Institute, 2000)

Lean today is widely applied in manufacturing and transactional environments across

many industries in private, public and government sectors.

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Types of Waste

The seven types of waste is a concept created by Taiichi Ohno and first written about
by Shigeo Shingo, the concept is from the Toyota Production System. (Lean
manufacturing, 2012)

Defects
This includes all time spent doing something incorrectly and inspecting or fixing
errors. One example of defect waste is the time spent looking for an item missing
from a surgical case cart. And a label on a blood tube that is misapplied, illegible or
improperly aligned can cause errors or delays in processing.

Over-production
This includes doing more than what is needed by the patient or doing it sooner than
needed. A broad example of this is the performance of unnecessary diagnostic
procedures. This waste shows up most commonly in batching work such as test,
paperwork or claims in a hospital

Transportation
Unnecessarily moving patients, specimens or materials throughout a system is
wasteful. This type of waste is evident when the hospital has a poor layout, such as
a catheter lab located a long distance from the emergency department.

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Waiting
Waiting for the next event to occur or the next work activity can eat up time and
resources. Patients waiting for an appointment is a sign of waste, as is employees
waiting because their workloads are not level.

Inventory
Hospitals create waste when they incur excess inventory costs, storage and
movement costs, spoilage and waste. One example is letting supplies expire and
then disposing of them, including out-of-date medications.

Motion
Do employees move from room to room, floor to floor and building to building more
than necessary? That accounts for one type of waste. Lab employees may walk
miles per day due to a poor hospital layout, for example.

Over-processing
This describes work performed that is not valued by the patient or caused by
definitions of quality that aren't aligned with patient needs. One example is extra data
stamps put onto forms, but that data never being used.

Human potential
This waste is caused when employees are not engaged, heard or supported.
Employees may feel burnt out and cease sharing ideas for improvement. (Beckers
Hospital Review, 2015)

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Lean Improvement Techniques

Value Stream Mapping

Value stream mapping (VSM) uses symbol to create a map of the patient or product
flow through the organisations and the flow of information associated with the patient
or product. The value stream map differs from a flow chart or process map in that it
provides valuable information associated with the flow of the process. (Thomas
2006)

5S workplace Organisations

Sort

Sort is getting rid of what is not needed. Unnecessary items were removed
from the work spaces. All incomplete work was completed or removed from
the area. The team created a red tag area to hold items that required a
decision, such as whether the items needed repairs and replacement. All work
areas, cabinets, and drawers were cleaned, organised, and labelled for
contents.

Set in order/Straighten

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Straighten involves placing the items in the order of flow. The team made sure
that all work areas, storage areas, and equipment were clearly marked and
well organised.

Shine/Scrub

Scrub is the cleaning portion of the checklist. All areas of the department were
cleaned. This was a huge undertaking because the backstage portions of a
hospital are often ignored in this regard. All garbage and recyclables were
removed and discarded or recycled

Standardise

The rapid improvement team identified the roles of the staff and defined the
standard tasks with regard to keeping the area clean and orderly. The team
posted visual management tools to keep track of whether tasks were
completed.

Sustain

The last and the most difficult of the five Ss is sustain. The sterile processing
team now follows posted standard work guidelines and standard cleaning and
work procedures. They also use standard information boards that contain
current and relevant information. (International Journal of Business and Social
Science, 2014)

Visual Management

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Visual management is one of the core elements of a Lean Management System
(LMS), and is commonly employed in organisations committed to developing the
delivery of value to customers. Some frequently used examples of visual
management in healthcare include bed boards, patient tracking systems, surgery
flow boards, strategy deployment boards, and daily huddle boards (Lean Healthcare
Exchange, 2015). Regardless of its specific form, visual management helps
organizations do several things:

Communicate about things that matter

Have everyone pulling in the same direction
Create transparency and increase trust
Create common information for shared decision making
Share and spread improvements

Kanban

Kanban is a Japanese word means sign board. A Kanban signals that an item
requires replenishing. The signal may take any form. It may be card, a square
painted on floor, an empty bin, an alarm, or a light. The Kanban should afford a quick
response to a need, should provide precise information regarding what is needed
and should be inexpensive to implement. (Thomas 2006)

Poka-yoke

Poka-yoke simply known as mistake proofing. Of note, the term poka yoke is of
Japanese origin and is one of the handful of the more commonly used Japanese
terms that have become mainstream in Lean circles. Poka yoke keep processes
from producing errors. Preventing errors obviously improves quality, but it also plays
a major role in improving productivity. With no rework, and easier production, cycle
times and lead times both become much shorter. And, of course, faster production
with fewer defects means lower costs.

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While the term poka yoke originated on the shop floor, it is equally relevant in office,
healthcare, and service settings. (Velaction Continuous Improvement, 2014)

Hospitals used the lean method to improve healthcare processes and quality

Carolina Hospital
Lean manufacturing principles are responsible for a significant drop in
emergency and a big boost in patient satisfaction at Stanford Hospital and Clinics in
California. Best of all, the approach didn't expand the ED's current resources,
Marlena Kane, executive director for performance excellence & medicine services at
the hospital.
Lean management as conceived by the Toyota company is based on constant
improvement and valuing people.
The hospital formed a multidisciplinary team led by nurse leaders and physicians to
meet increased demand and improve the patient experience in the ED.
They applied lean principles, engaging frontline staff and empowering them to
handle issues and problems as they came up. Staff then worked with other
departments to isolate and resolve inefficiencies.
Within a year, she said, ED wait times dropped by 17 percent, in spite of the fact that
the department treated more patients than the year before. The operating costs
stayed the same.
Some "safety-net" hospitals are already using lean manufacturing concepts to
streamline their own operations and function more effectively. A North Carolina
hospital system has incorporated the system to reduce patient falls by 22 percent
and improve safety. (David Ferguson 2015)

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Manitobas St. Boniface General Hospital

Manitobas St. Boniface General Hospital is using Lean. One of their projects was to
reduce wait times for CT scans last year. Staff ran a Rapid Improvement Event,
where a team mapped out patient flow and looked for possible improvements. And
they found them. After cutting out repetitive forms, removing unnecessary steps and
creating a single patient registration spot, wait times dropped from an average of 26
minutes per patient to eight minutes.
In 2007 the hospital began working with Lean, and has since gained a reputation for
being one of the strongest supporters of the process. But its far from the only one,
as Lean is being implemented in health care institutions across the country.
Proponents believe the efficiency-focused philosophy reduces waste and offers a
solution to our increasingly burdened health care system. (Milne, Pendharkar and
winkel 2014)

Tan Tock Seng Hospital

TTSH subscribes to LEAN principles in its aim to provide faster, better, cheaper and
safer patient care. Under its MyCare process improvement framework, there is a
constant review to fine-tune work flow and improve patient care coordination.
Its Emergency Department for example has successfully reduced the number of
stations that patients have to go through by 50%, while improving the quality of their
care. TTSH has also experimented with a new U-shaped layout at its clinics to
facilitate "one-direction flow" for patients in 4 simple steps. Adopting best designs
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from top hospitals overseas, the new clinic consultation rooms have also been redesigned to bring the doctor closer to the patient. This helps to facilitate better
patient-doctor communication (Tan Tock Seng Hospital 2015)

Conclusions

Lean management is not a new concept, but it is almost new to health care. While
critics are right when they say, Patients are not cars, medical care is, in fact,
delivered in extraordinarily complex organisations, with thousands of interacting
processes, much like the manufacturing industry.

Value Stream Mapping is the most frequently applied Lean tool in healthcare. The
process orientation is crucial, but still weak in healthcare organisations.

There are some challenges which face the implementation of Lean in the healthcare
including:
Healthcare staff do not like care services being compared to car assembly lines.
They believe that their organisational settings and problems are unique and cannot
be simply solved by methods coming from manufacturing industry.
There is a lack of educators and consultants who have their roots in the healthcare
sector and can provide support by sharing experience and giving examples from
real-life applications of Lean in healthcare.
The key principle in Lean is to understand value as seen by the customer. The term
customer in healthcare is not straightforward

The Institute for Healthcare Improvement believes that many management and
operations tools in other industries can be applied successfully to health care. Lean
principles hold the promise of reducing or eliminating wasted time, money, and
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energy in health care, creating a system that is efficient, effective, and truly
responsive to the needs of patients the customers at the heart of it all.

Referencing

Lean Enterprise Institute 2000, What is Lean? Available from:

http://www.lean.org/WhatsLean/ [10 November 2015]

Campbell, Robert James 2009. Thinking Lean in Healthcare: Journal of AHIMA 80,
no.6. pp 40-43.

Lean Enterprise Institute 2000, A BRIEF HISTORY OF LEAN. Available from:

http://www.lean.org/WhatsLean/History.cfm [10 November 2015]

Wikipedia, Lean manufacturing: Types of Waste, (wiki article), October 8, 2012.

Available from: https://en.wikipedia.org/wiki/Lean_manufacturing#Types_of_waste
[15 November 2015]

Thomas G. Zidel, 2006. A Lean Guide to Transforming Healthcare: How to

Implement Lean Principles in Hospitals, Medical offices, clinics and other Healthcare
Organizations. United States of America. p 28.

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Beckers Hospital Review, 2015. 8 Types of Waste in Healthcare. Available from:
http://www.beckershospitalreview.com/hospital-management-administration/8-typesof-waste-in-healthcare.html [15 November 2015]

Thomas G. Zidel, 2006. A Lean Guide to Transforming Healthcare: How to

Implement Lean Principles in Hospitals, Medical offices, clinics and other Healthcare
Organizations. United States of America. p 59.

International Journal of Business and Social Science, September 2014. The Use of
5S in Healthcare Services: A Literature Review. Available from:
http://ijbssnet.com/journals/Vol_5_No_10_1_September_2014/30.pdf [28 November
2015]

Lean Healthcare Exchange, 2015. Visual Management What Makes It Tick?

Available from: http://www.leanhealthcareexchange.com/?p=5236 [28 November
2015]

Velaction Continuous Improvement, 2014. Poka-yoke. Available from:

http://www.velaction.com/definition-poka-yoke/ [30 November 2015]

David Ferguson 2015, Fierce Healthcare: How lean manufacturing improved ER wait
times, satisfaction at a California hospital. Available at:
http://www.fiercehealthcare.com/story/how-lean-manufacturing-improved-er-waittimes-satisfaction-california-hospi/2015-10-16 [2 December 2015]

Vanessa Milne, Sachin Pendharkar & Gord Winkel 2014. Healthy Debate: From the
factory floor to the emergency department: Hospitals explore Lean method. Available
at: http://healthydebate.ca/2014/09/topic/lean [5 December 2015]
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Tan Tock Seng Hospital 2015, TTSH Most Improved Hospital in 2010. Available at:
https://www.ttsh.com.sg/about-us/newsroom/press-releases/article.aspx?id=2039 (5
December 2015)

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