Why Lean Might Not Be the Best Solution to Healthcare Inefficiencies

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In an effort to eliminate efficiencies and streamline processes, many hospitals have turned to Lean, a process improvement framework adapted from the manufacturing-based Toyota Production System. Using Lean strategies, hospitals map out current processes, identify non-value-added steps and redesign the process to eliminate these wasteful steps. Many hospitals have successfully improved processes using Lean principles, reducing emergency department wait times, speeding stroke treatment and reducing costs, for example.

Pierce Story describes the need for a dynamic approach to healthcare process improvement.The need for a dynamic approach
However, one flaw in the Lean strategy is that Lean is predicated on the assumption of a stable, contained process in which variation has little significance. In the manufacturing industry, this assumption holds true, as processes are largely carried out on production lines with standard materials and products. In healthcare, however, processes are more dynamic and involve highly variable, interdependent systems.

Pierce Story, founder and director of concept development at Capacity Strategies, believes the variability in healthcare calls for a dynamic approach to process improvement that leverages some strategies from Lean while also building in the ability to change processes to meet changing needs. "Healthcare systems are highly variable and interdependent. Those systems evolve and change over time. Lean isn't adapted well to those sorts of highly dynamic environments."

Moving from process improvement to systems improvement

Although healthcare is variable, the industry can still take advantage of the efficiencies gained from standardization. Mr. Story suggests "dynamic standardization — a standardized work concept that says if you have a standardized work process that's good for certain circumstances, you may need an altered process as the circumstance changes, which becomes another standardized process."

Under dynamic standardization, hospital leaders may use traditional Lean tools to optimize single processes for single circumstances — process improvement — while using a more dynamic approach to apply resources and altered processes to predicted changes in the hospital environment — dynamic systems improvement. "Healthcare needs its own improvement methodology that is inclusive of a lot of principles of Lean and Six Sigma, but that incorporates analytics and approaches that account for the dynamism of our environments. For instance, Kaizen [a Lean term for continuous improvement] is great for process improvement, but not necessarily great at systems improvement efforts like department-wide or hospital-wide flow," Mr. Story says.

Dynamic capacity management
Applying different standard processes to different situations — this combination of traditional and dynamic strategies — is a required capacity management skill. Capacity management is essentially the ability to match one's dynamic capacity — the resources in terms of staff, materials and space — with dynamic demand — the ever-changing number and types of patients. To successfully match demand and capacity in a variable environment such as a hospital, leaders need to identify how demand and capacity vary, and determine patterns in variation that can help hospitals deploy resources appropriately.

Mr. Story calls managing capacity to deal with variable demand and interdependent operations "dynamic capacity management."

Identifying variable demand and capacity
One way hospital leaders can identify changes in demand is to consider patient volume patterns and the resulting patterns in workload in the ED, operating room and other units by hour, day and season. Similarly, to identify changes in capacity, hospital leaders should consider changes in staffing, skill mix, workflow and processes across shifts, days and seasons. Fortunately, while both demand and capacity vary, these changes are often quite predictable. Hospitals can review patient arrival data to determine their peak ED volume patterns, for example. Hospitals also know their staffing schedule changes for nights, weekends and holidays. "You want to discern any kind of demand and operational patterns that can show consistency over time, then manage to those patterns," Mr. Story says.

Technologies such as real-time locating systems are increasingly used to help hospitals identify demand and capacity, according to Mr. Story. "Those can be handy, but they're often misused and over-utilized," he says. He says many hospital leaders use them as alerts for when volume spikes or resources become available or scarce, but the alerts are often too late. "It doesn't help if the smoke signal goes off if the house is already burning down," he says. "I needed to know of a pending issue three, four hours ago so I could change my workflow to accommodate what was going to be hitting me. Furthermore, we often layer these technologies on before we create dynamic capacity management capabilities, yielding poor results."

Therefore, he suggests that using predictive analytics is a more important, and less expensive, tool for anticipating capacity needs, enabling hospital leaders to prepare to meet increases or decreases in demand.

Match variable demand and capacity

Once hospitals identify the patterns of variable demand and capacity, they can more easily allocate resources as needed. One way hospitals can improve their ability to match variable demand and capacity is to perform simulations that build instincts in hospital staff. Mr. Story says there is a need for "simulations and predictive analytics, and an instinctive approach to information by staff members to lessen the need for heavy IT implementations."

Hospital leaders can simulate high-demand situations, such as a surge in the ED, and train hospital staff on how to best react so when a similar situation does occur, staff members are prepared and take appropriate mitigation steps. "We need to be able to create those kinds of reactions among our staff as certain circumstances play out. The only way to do that is to use a lot of experiential knowledge developed from the use of predictive analytics," Mr. Story says.

These instinctive responses to predicted changes become dynamic, standardized processes; the ability to respond with different standard processes for different scenarios is dynamic capacity management. By recognizing and preparing for the variability in healthcare, leaders can more effectively eliminate inefficiencies and improve outcomes.

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