This is Chapter 11 of 50 in a summary of the textbook Handbook of Healthcare Delivery Systems. Go to the series index here. Listen on YouTube Playlist, or search your podcast app: Gregory Schmidt
Chapter 11 Summary
Lean in Healthcare
Chapter Authors
Philip C Jones - University of Iowa
Barrett W. Thomas - University of Iowa
Some Comments
There are dozens of blogs, articles, and books written on Lean in Healthcare. This chapter is a quick overview of Lean, and not designed as a full training course.
This chapter was written almost a decade ago (book published 2010), and it is interesting to see at the time how the authors were clearly were concerned on demonstrating that Lean is applicable to Healthcare and a valuable tool. Conclusions that today are now taken at face value.
I trained in a hospital that was an early leaders in Lean methodology in healthcare. I have seen firsthand its positive impact. I’ve also been able to see Lean at peak implementation in the industrial setting, and was absolutely blown away by how effective it can be when done right.
1. Introduction
The chapter opens by recognizing the elusive desire to provide high-quality healthcare at reduced costs. However, political will and major changes to the system have been unable to do this.
A second approach is proposed, one that does not require major system changes or political will. It is called ‘Lean’.
The authors admit they do not have randomized controlled trials and standard experiments proving the benefits of Lean in improving the healthcare system. Instead, they propose series of compelling case studies. Almost a decade on from this book’s publication, the case studies are so numerous that belief in Lean as a tool to improve healthcare is well established.
2. Before Lean: Taylorism
Healthcare adopted ‘classical industrial engineering techniques’ in the 1940s. These were often derived from the works of Frederick Taylor (1856-1915) - the founder of “scientific management”.
Taylor invented the time and motion study. This tracks the work of an employee over time. He was so specific that he decided 21.5lbs was the optimal load for people to shovel, and then designed tools that scooped exactly this.
His methodology is one of management specifying with precision the ‘correct’ way for something to be done, and then the never-idle employee carries it out with maximal efficiency.
The text describes Taylor’s philosophy as
“1. Replace rule of thumb work methods with methods based on a scientific study of the tasks.
2. Scientifically select, train, and develop each employee rather than passively leaving them to train themselves.
3. Provide “detailed instructions and supervision of each worker in the performance of that worker’s discrete task”
4. Divide work nearly equally between managers and workers, so that the managers apply scientific management principles to planning the work and the workers actually perform the tasks.”
3. Lean: an introduction
3a. The origins of Lean
Lean was developed by Taiichi Ohno (1912 - 1990). It became popularized as part of the Toyota Production System in the 1940s. The goal is to continuously improve the organization.
Lean places the mandate to improve not just on the management, but upon each individual worker to seek how they can do their job better, and work with others to improve it. A stark contrast from Taylorism described above - where there is a ‘correct way’ to do something, and workers ought to do it without thinking.
3b. 14 Principles of the Toyotal Production System
The chapter lists 14 principles of the Toyota Production System as listed by Liker (2004)
1. Base your management decisions on a long-term philosophy, even at the expense of short-termfinancial goals.
2. Create a continuous process flow to bring problems to the surface.
3. Use "pull" systems to avoid overproduction.
4. Level out the workload. (Work like the tortoise, not the hare.)
5. Build a culture of stopping to fix problems, to get quality right the first time.
6. Standardized tasks and processes are the foundation for continuous improvement and employee empowerment.
7. Use visual control so no problems are hidden.
8. Use only reliable, thoroughly tested technology that serves your people and processes.
9. Grow leaders who thoroughly understand the work, live the philosophy, and teach it to others.
10. Develop exceptional people and teams who follow your company's philosophy.
11. Respect your extended network of partners and suppliers by challenging them and helping them improve.
12. Go and see for yourself to thoroughly understand the situation.
13. Make decisions slowly by consensus, thoroughly considering all options; implement decisions rapidly.
14. Become a learning organization through relentless reflection and continuous improvement.
4. Lean: its tools
4a. 7 (or 8) wastes
Waste in lean is activity that does not produce value for the customer. Waste should be identified and eliminated. Doing so helps with Principle 2 (continuous process flow). The text defines the wastes as:
“1. Overproduction
2. Waiting
3. Unnecessary transport or conveyance
4. Overprocessing (or incorrect processing)
5. Excess inventory
6. Motion (ofworkers)
7. Defects
8. Unused employee creativity”
4b. Takt time analysis
A level workload (Principle 4) means production should match the rate of customer demand. This concept is similar to industrial engineering idea of ‘line balancing’, but the goal here is to match the customer.
4c. 5S (or 6S)
Principle 6 & 7 look for standardized work, visual controls, and employee engagment in this process. This can be accomplished with the following 6Steps.
“1. Sort (separate out unneeded items)
2. Straighten (a place for everything and everything in its place)
3. Shine (clean the workplace up)
4. Standardize (create standard rules, standard work, and standard procedures)
5. Sustain (maintain the improvements you have made)
6. Safety
4d. 5 Whys
When a problem occurs, the 5 Whys encourage an organization to ask a series of “Whys” with the goal to arrive at the root cause of why something happened.
Without continuing to ask Why and go back to the root cause, the organization will instead only fix a symptom and not the real issue. This supports Principles 13 & 14 - to become a learning organization that reflects, and makes decisions by consensus.
4e. Value stream mapping (VSM)
Value stream mapping takes the idea of process flow mapping (looking at the steps to produce a product), and adds in more details about the process at each step.
4f. Kaizen events
Kaizen events (also called Rapid or Continuous Process Improvement events) support Principle 13 & 14 in employee engagement in organizational improvement.
The objective of a Kaizen event is to gather everyone together who is involved in a process over two to five days. During this time a value stream map is created of the current state, waste is identified, the root cause of the waste identified, solutions are proposed, and everyone agrees together on the new process.
5. Lean vs Six Sigma
Six Sigma was developed by Motorola in the 1980s, and popularized by General Electric. It is a methodology with the goal of reducing variance in its production.
If an organization operates at three sigma although it will produce an output with 99.73% tolerance. However, this output is a normal distribution, and if shifts by 1.5 standard deviations the total output drops to 93.3% within tolerance. This is obviously problematic when producing at scale. Furthermore, if a final output requires the summation of 5 processes, and each process operates at 93.3% accuracy then the final summed yield is 70.7%.
The objective of Six Sigma is to try and operate so that only two parts per billion are outside of the design tolerances. This means that if the process shifts by 1.5 standard deviations many fewer products will be outside of the variance.
5b. Lean vs Six Sigma
Are these processes the same or different? Are they in conflict?
Six Sigma looks to reduce production variance. There is less focus on ‘waste’ and organizational behaviour compared to Lean.
Another significant difference is that Six Sigma requires intensive mathematics. The training in Six Sigma and its application is only accessible to those experts who can develop such skills and certify as a ‘Six Sigma blackbelt’.
Lean on the other hand is easier to teach anyone in an organization. It is also encouraged to get as many people in the organization on board.
5c. Why is Sig Sigma important in healthcare?
The book quotes some sobering numbers. If healthcare operated at three-sigma it would result yearly in 20,000 incorrect prescriptions, and 15,000 dropped newborns babies. Furthermore 12 babies would be given to the wrong parent per day.
My own unofficial estimates suggest parts of healthcare operate at close to two sigma.
6. Lean in Healthcare
The chapter lists multiple ‘wins’ of how Lean has been used in healthcare. If interested, just do a Google search to find your own examples. The results are impressive with everything from reductions in cost, length of stay, and mortality.
A set of observations the text references from 'Jones & Mitchell’s overview of Lean in Great Britain’s National Health Service' identify the following helpful advice:
- Lean must by locally led, not imposed from outside.
- Lack of standard work was a frequent and serious problem.
- Disconnects at the gaps between functional silos caused problems.
- Inappropriate metrics encouraged counterproductive behavior.
- Complex processes with many handoffs caused problems.
This is summarized by Jimmerson et al. on their work in Intermountain Healthcare, who commented “…at the root of every operational problem we’ve studied is a poorly specified activity, a vague unreliable connection, or a complex pathway'“.
Another way to group the quality problems in healthcare is by: overuse causes, underuse causes, and misuse causes.
Case Study
In incorrectly identifying what creates customer value & lack of communication.
A case study is presented at an Infusion Suite where the same nurse always works with the same patient during each encounter. It was assumed this was of value to the patient. This resulted in asymmetric resource allocation because at times some nurses were idle and others had growing queues. The reality is that when polled, patients valued spending less time in the clinic above seeing the same nurse.
The example of lack of communication is interesting. Often I think of lack of communication within a team, but the chapter provides an example of lack of communication between the clinic and patients. At the same infusion suite patients typically came during the mid-day. This led to long lines. By communicating to patients the availability of free spots in the morning and late afternoon, the clinic’s workload balanced.
In another case study, the rate of nurses interruptions while transfering an order was approximately 1 per minute. “The result was that the average ordered required just over 7.5 hours to be processed with a range of 1 minute to over 13 hours.”
Queues and Wait Lines
This build upon the prior chapter’s discussion of wait lines. The authors comment on the misguided assumption that ‘optimal’ utilization of a system is 100%.
The issue is that the queue increases nonlinearly as discussed in the prior chapter.
Therefore in manufacturing a ‘rule of thumb’ is to add more capacity when utilization exceeds 80%. Otherwise overall productivity may actually drop off.
I shutter to wonder the inefficiency that results from the prior hospital I worked at which ran at excessive of 105% capacity.
7. Lean: difficulties encountered during implementation
Implementing lean takes time. The book identifies six hurdles:
Resistance to change: this occurs whenever any change is brought into the workplace. Doctors are often most resistant, so therefore starting with non-physician personal is a good place.
Narrow focus on tools: Lean and its tools are just one of many systems for organizational improvement. It doesn’t have to be, and shouldn’t be, used to solve every problem. There is no need to turn Lean into a cult.
Impatience: the authors’s experience suggests it takes 2-3 years for the small improvements in Lean projects to begin improving higher level strategic goals. But in order for the button line and customer value to be fully delivered Lean cannot be left in silos and must spread through the organization.
Lack of humility: once you believe everything in your organization has been “Leaned outed”, by definition you stop improving, and eventually productivity will drop off.
Lack of initial and ongoing senior management involvement: the senior management are required to not only rubber stamp adopting Lean initiatives, but must take part in them themselves and work alongside the rest of the employees.
Sustainment is hard: Lean is not self sustaining. Continuous energy is required for Lean to remain a tool and lens for an organization to use.