How to Get Hospitals to Think 'Lean': 5 Key Principles

What does car manufacturer Toyota and Lucile Packard Children's Hospital at Stanford University have in common? More than you might think.

Hospitalists at the Palo Alto, Calif.-based children's hospital have started successfully using the same 'Lean' business and management strategy made famous by the Japanese car company: promoting the endless transformation of waste into value from the customer's perspective. Other hospitals and healthcare systems, including Virginia Mason Medical Center in Seattle and Appleton, Wis.-based ThedaCare, have increased productivity and cut costs using a similar Lean model.

Terry Platchek, MD, a clinical instructor at Packard and co-author of Lean Healthcare for the Hospitalist, an academic paper on Lean care delivery, explains how Packard has implemented a clinical care delivery model based on the principals of the Japanese car maker. Here are five key principles of Lean thinking in a hospital setting and examples of how it's helped Packard improve care.

1. Achieving value outcomes with the least amount of work possible. Value is a crucial component of Lean care, and something that needs to be seriously discerned. "In healthcare, value is something that changes the form, fit or function of a treatment or process," Dr. Platchek says. "It will help alleviate pain or remove suffering."

Thinking Lean in a hospital setting involves considering the definition of value from a patient's perspective and putting in place efficient clinical changes to provide valuable care. It's essentially a shift in mindset, moving from viewing clinical care as a series of tasks to be completed as quickly as possible to a process that can be continuously improved on to achieve the goal of valuable outcomes for patients.

This doesn't mean that physicians in a Lean healthcare organization will need to work longer, spending more time with every patient. In contrast, the goal in a lean hospital is to "achieve valuable outcomes with the least amount of work possible," Dr. Platchek says.

One way Packard achieved valuable outcomes without increasing workload was to change the time physicians enter in their orders to immediately following the patient visit. Typically, physicians make rounds and place an order at the end of their shift. "From the patient's perspective those hours of waiting are not valuable," he says.

Dr. Platchek says his hospital has seen drastic improvements since making that simple change. And the changes have made the physicians' lives easier since they do not have to return to notes from hours ago when putting in orders at the end of a long shift.

2. Cutting out waste from the care delivery model. In order to identify the value of care being delivered, hospitals need to remove any processes weighing them down. The Lean model involves constantly, almost scrupulously, vetting wasteful processes, such as overly long patient wait times and unnecessary documentation protocols.
Dr. Platchek identifies eight categories of waste and an example of what the waste might look like in a hospital setting:
  • Overproduction (ordering unnecessary tests)
  • Waiting (the time between lab specimen arriving and start of an analysis)
  • Material movement (moving charts from workroom to workroom)
  • Motion (traveling between multiple wards during rounds)
  • Inappropriate processing (multiple care providers reentering patients' social history without obtaining any new information)
  • Inventory (patients waiting for long periods in examination rooms)
  • Correction (wrong medication administered because of illegible handwriting)
  • Underutilization (physicians transporting medically stable patients)

Dr. Platchek discusses a structural error Packard fixed to cut waste and improve the value of its delivery model. The supply room at the hospital was positioned in an area inconvenient for nurses. So the hospital decided to fix the issue and put the supplies where the nurse usually is — by the patient's bedside.

Packard also found ways to cut down on patient wait time for operating rooms. The hospital entirely eliminated its pre-operation holding area for ambulatory patients; this cut about 45 minutes from the pre-operative process, Dr. Platchek says. Additionally, the hospital changed the way anesthesiologists bring patients into the operating room. It used what Dr. Platchek calls a "one-piece flow model" where the anesthesiologist brought young patients back directly along with a parent who could be present for the induction.  

By implementing a Lean care model and identifying and correcting wasteful processes, the hospital was able to reduce wait times for operating rooms from two hours to 60 minutes in a span of two weeks.

"You can cut out fifty percent of the waste in about a week," Dr. Platchek says. "It takes a lot of effort, involvement of the front line worker and some upfront cost, but we can improve these processes."

3. Identifying value streams. Value streams refer to any series of steps that create a valuable product. The way to improve a value stream is to reduce waste and to create a process that flows to a valuable output.

Dr. Platchek says for healthcare, a value stream would technically be something such as oncology care or asthma care, and the stream would track care from beginning to end both inside and outside the hospital. The problem is this is very difficult to do since so many systems interact to provide care. Thus, hospitals using a Lean care system may refer to shared services as value streams. While this is not technically correct, Dr. Platchek says, it's correct in spirit.

He adds that the more complex a system or series of processes, the more difficult it becomes to understand the interactions between individual elements of the system and identify the waste in a value stream.

"Waste hides in complex systems, and healthcare is an immensely complex system," he says. "If we highlight the value of adding steps in a process, such as giving the correct medicine at the correct time, we can focus on improving and reducing the wasteful steps in the process."

4. Knowing why jidoka and "just in time" are important. Aside from being an interesting sounding Japanese word, jidoka is one of the two crucial pillars of Lean thinking. Loosely translated, the word means "built-in quality" and refers to the idea that when a problem arises, a Lean system has in place the equipment to prevent defective products from being produced. This again goes back to Toyota; Sakichi Toyoda invented a device to automatically detect and stop a loom when a thread broke, thereby providing an opportunity to fix a production problem before a defect was created in the textile.

Dr. Platchek says for Lean hospitals and healthcare organizations, jidoka means seeking to identify defects in their care delivery system as close to the source of the problem as possible without halting the delivery. This involves constantly monitoring and improving healthcare delivery abilities.

The other important pillar of Lean thinking is "just in time," which means that each process produces the right items at the right time in the right amounts. A Lean production system is able to respond to the day-by-day shift in customer demand. In a Lean hospital, the volume load of staff on duty in every part of the hospital matches the demand of peak patient volume times. Errors in hospitals are sometimes the result of staff feeling rushed and cutting corners because of a high volume of patients, Dr. Platchek says. With more hands on deck at the right time, the "just-in-time" pillar of lean thinking may improve the value of care delivered.

5. Taking a Lean approach to problem solving and using standard methodology. A Lean hospital strategy needs the support of not only physicians, but the entire hospital staff. "Every healthcare worker needs to be a problem solver," Dr. Platchek says; he adds that it takes every single person working in a hospital to make the Lean model function, from physicians to the janitorial staff.

The lean approach says physicians and staff need to identify a problem, understand the process, observe it and collect valuable information. In short, a Lean hospital strategy involves understanding the root of inefficiency or patient dissatisfaction. In developing a solution, hospitals need to involve the frontline workers in the solution they're going to try, Dr. Platchek says.

It's similar to how a physician takes a history of the patient and performs a physical exam. "We can come up with better solutions to problems in our care delivery model when we use standard methodology," Dr. Platchek says.

He insists there needs to be some kind of standard providers use within a Lean hospital to measure efficiency.

"The only variability should stem from our patients," he says.

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