Lean in Hospitals

“Introducing Lean to the Hospital”

Peter D. SchellinckPartner SHConseil+32 496 386 437www.shconseil.frwww.schellter.eu

Agenda

The Crisis of Waste in Healthcare

Lean Thinking Principles in Healthcare

Benefits for:

Patients Employees Hospitals

Hospitals Are Dangerous…

CDC 1998:

90,000 killed and 2,000,000

injured from hospital-caused

drug errors & infections

Preventable Errors Abound…

“… 3 to 5% of specimens taken

each year are defective… blood that isn’t drawn

correctly… mix-up with another

patient’s sample”

Preventable Errors Abound…

Preventable Errors Abound…

Mass Production or Healthcare?

Large batches

Sub-optimizing one resource

Lack of employee input

One-person/One-machine

Quality through inspection

Automation is the answer

Lack of standard processes

Not communicating metrics

Lack of leadership

Constant fire fighting

Non-Lean, Current Thinking

1. Specify value in the eyes of the provider (or the payer)

1. Identify your department and sub-optimize it

1. Make patients wait for the convenience of the system

1. Ignore some employees and devalue others

1. Continuously fight the same fires in the pursuit of surviving the day

Applications of Lean in Healthcare

Laboratories Reducing Turn Around Times and Errors

Emergency Departments Reducing diversions, improving flow

Outpatient Cancer Treatment Reducing patient delays, increasing capacity

Operating Rooms Reducing changeover times, increasing utilization

Pharmacies Reducing errors, improving response

Food Service Reducing wasted food, improving quality

Why LEAN Works in Healthcare

LEAN is not a list of tools that applies only to factories

LEAN is a philosophy of management that applies to any system

LEAN rallies people around goals we can all agree on:

Patients and Employees for

Quality

Not About Cutting Heads

Shortages of skilled employees

51% of hospital med techs greater than 45 years of age, vacancy rate at 11%

Shortfall of 65,000 nurses expected by 2012

Do more…

With the same Eventually, with less

Not Only About Cutting Costs

Hospitals are using lean as a Business Strategy

Improving quality

Improving service

Improving employee satisfaction

Growth strategies

“Un-outsourcing” testing work

Source: LEAN Thinking, Womack and Jones 1996

Principles of LEAN Thinking

1. Specify value in the eyes of the customer.

– The customer must be willing to pay for the activity

– The activity must change the form, fit or function of the product or service

– The activity must be done right the first time

Who are the “customers?”

Principles of LEAN Thinking

1. Specify value in the eyes of the customer.

2. Identify the value stream and eliminate waste.

13% of hospital costs are due to controllable waste.

Source: Zuckerman, Hadley, and Iezzoni, 1994

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Typical Organization is Silo-ed

Value Stream – Anatomic Pathology

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SpecimenCollection

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Types of Waste – Lab Examples

Defects

Overproduction

Transportation

Waiting Time

Inventory

Motion

Processing

Human Potential

Label on the wrong tube

Drawing all blood at 4 AM

Long walks, multiple handoffs

Tube waiting on centrifuge to fill

50 weeks of supply

Tech walking 80 ft to the printer

Time/Date stamps added, not used

Administration not listening to Med Techs or ideas for improvement

Are We Tolerating Waste?

Healthcare = Workarounds Professor Steven Spear

“Decoding the DNA of the Toyota Production System” (HBR)

“Fixing Healthcare Today From the Inside” (HBR)

Case Example: 10-20% of MD orders are missing EVERY DAY

Call and get the order – done? Tomorrow, we’ll do the same

Problems need to be seen as opportunities

Laboratory Layouts Drive Waste

Layout is driven bydepartments

Benches interfere withstraight-line walking, encourage batches

Clinical Laboratory Product Flow

Clinical Laboratory Timeline

Total CT = 5.44 hours

Med Tech Walk Pattern Pharmacist Walk Pattern

Layouts Drive Waste of Motion

Cancer RN Walk Pattern

Kms per Day!

Typical 5S Baseline

Unorganized Workbenches Product Flow not Obvious Time wasted looking for things Hoarding of supplies

Poor Utilization of Space General Clutter Supply Shortages and

“Hidden” Inventories

5S Improvement Examples

Principles of LEAN Thinking

1. Specify value in the eyes of the customer.

2. Identify the value stream and eliminate waste.

3. Make value flow at the pull of the customer.

Mass Production Thinking Utilization

Keep expensive assets heavily utilized Machines Doctors

The tradeoff is waiting time Cars

Patients

Lean Thinking Flow

Focus on reducing Patient Waiting time

Reducing Patient Wait Times

B

A

PATIENT

ARRIVAL TO TREATMENT

(HOURS)

LATENESS FOR TREATMENT

(HOURS)A 2,5 0,42B 3,5 1,08

AVG 3,0 0,75

• Blood drawn• MD consult• Needle into Port

• Check In / Check Out• Moving from room to room

• Waiting for Check In• Waiting for MD• Waiting for Treatment

Value Added

NVA But Required

NVA, “Pure Waste”

Outpatient Oncology Patient “Flow”

Re-Work Loops Cause Delays

Batching Prevents Flow

Batching Hurts Quality

Lack of “standard work” and opportunity for “error proofing” – Anatomic Pathology

Batch of slides made, 3 patients, risk of mixup?

2nd histotech labels one slide at a time

Batching Hurts Quality

Lack of “standard work” and opportunity for “error proofing” – Pharmacy

Flow

You can’t have flow without some amount of “leveling” in the system

“Leveled Production:

You won’t be Happy without it”

From Toyota publication

39% of Samples Arrive in Just 3 Hours of the DayTAT expectations are constant

Typical Hospital Lab Not Level

Shift ShiftShift

Leveling Reduces Peak Costs

Principles of LEAN Thinking

1. Specify value in the eyes of the customer.

2. Identify the value stream andeliminate waste.

3. Make value flow at the pull ofthe customer.

4. Involve and Empower employees.

5. Continuously improve in the pursuit of perfection.

Pre-Lean Med Tech Quote:

“With all of the automation,

I feel like a robot.”

The “Thinking Production System”

“Perhaps the greatest strength of the Toyota Production System is the way it develops people.

This is why the T actually stands for ‘Thinking’ as well as for ‘Toyota.’”

Teruyuki Minoura, Toyota

Source: USA TodayAugust 24, 2005

What Mistake-Proofing Means to Healthcare

The Global Goal: Reduce Medical Errors

“Human error is inevitable. We can never eliminate it.” …..

We can eliminate problems in the system that make it more likely to happen.”

Liam DonaldsonWHO World Health Alliance

for Patient safety

Traditional Approach: “Naming, Shaming, and Blaming”

Lean Approach: Supports open reporting of mistakes Root cause problem solving process “Anyone can make mistakes”

Lean Requires a Cultural Shift

Error Proofing Example

Micrograms or Milligrams?

A medical mistake waiting to happen when written by hand

Error Proofing Example

Confusing

Unambiguous(Lean)

MD Resistance to Standard Work

“… some surgeons make a tiny, mole-sized mark on a patient instead of a big, bold "X”…. I call them passive-aggressive marks…” USA Today, 4/18/06

Which isMore effective?

Lab Benefits from Lean

Productivity improvement >30%

Space savings of >250 sq m

Standardized work practices

Reduction in Errors and Error Potential

Test Turnaround Time (CT) reduced by 50%

Reflections on Year’s in Healthcare

Lean is a powerful methodology

People are people

Healthcare people have incredible intrinsic motivation

Humility and asking questions is better than being a know-it-all

Coaching the team to “do lean & be lean” is the only sustainable route