By Ken Boyer, Ohio State University, Boyer_9@fisher.osu.edu
After a coincidental meeting with Ian Black, the then lean director of Boeing, Gary Kaplan, CEO of Virginia Mason, became convinced that lean production was the solution. In 2002, Kaplan and a team of executives and managers began annual trips to Japan to study at the Shinjijutsu International Center, one of the world leaders in the Toyota production system. On their return, staff immediately put into practice what they had learned and the benefits of implementing this new way of managing hospitals and patient care. Gains in productivity freed up 77 full-time equivalents (the number of full-time employees) with many being reassigned work in the newly developed lean promotion office. Defects in patient care reduced by 47 per cent while kaikaku workshops (see box) saved the hospital over US $12m during the period 2002 to 2004.
One change made in just five days using the kaikaku technique concerned the delay between a doctor's referral to a specialist and the first consultation. By examining the process closely it was found that the secretaries, whose job it was to arrange these referrals, were not needed. Instead the doctor would page or text the consultant the instant he decided a specialist was required. This specialist then had to respond in ten minutes, even if just to confirm receipt of the text. Delays in referral to treatment dropped by 68 per cent as a consequence.
On another occasion, staff in the radiation oncology department began an exercise looking at and mapping out the value stream with the intention of eliminating all the waste they could find. Due to the removal of these unnecessary non-value adding activities, which only soaked up resources, the time a patient spent in the department fell from three quarters of an hour to just 15 minutes.
Kaplan takes staff to Toyota's factories in Japan every year and practices what the car maker preaches. Just as the automaker's executives spend part of each day on the factory floor, Kaplan tours the hospital daily looking for problems and solutions. Everyone is encouraged to look for changes to make work more efficient. Nurses developed ways to spend most of their time with patients instead of at the nursing station. How? COWs – short for Computers on Wheels.At a meeting each week the staff reviews the results of what Toyota calls "Rapid Process Improvement Workshops," looking for ways to increase efficiency.
In their four day workshop, with the help of a home video camera, the staff of one clinic acted out what happens to a new patient. They came up with 10 things they would start doing differently immediately.
Virginia Mason reached out to area employers like COSTCO and asked them what they needed most from hospital visits.
"I care about quick treatment," said Katrina Zittnick with Costco. "Immediate appointments, the right treatment at the traumatic, acute time."
So at Virginia Mason's back clinic there were dramatic changes, where treatment time was cut from an average of 66 days to 12.
The application of lean techniques is expanding in healthcare. Britain’s National Health Service (NHS) is getting in on the act:
The NHS has been slower to fully embrace lean thinking but is now rapidly making up for lost time. Last January saw the first lean healthcare forum in Birmingham and a second was held in June. Chaired by author and prominent lean thinker Dan Jones, these forums have helped explain and consolidate lean knowledge.
One NHS organisation that has begun the lean journey is Bolton Hospitals NHS Trust. Under the direction of CEO David Fillingham lean has found its way into every department and management decision, reducing waste wherever it occurs and adding value to each step along the patients' care pathway. Staff too have become more motivated and focused on providing quality care to patients, with each employee responsible for analysing what they do and how they can do it better.
Lean has also been successful in decreasing the length of time inpatients stay in the hospital from an average of 34.6 days to just 23.5. The principal method for bringing about these changes involved looking at the whole supply chain's value stream as the patient travelled along his or her unique care pathway. Often, in organisations, change happens in a piecemeal fashion with separate departments initiating changes independently.
A lean approach, on the other hand, requires departments to consider from the start their positions in the supply chain and any impact their changes will make on the whole. By ensuring that all the necessary supporting services, such as health records, pathology and secretarial services, work together and come into play at just the right time, the patient, after entering the hospital and beginning the journey, does not need to be kept waiting between processes.
The patient moves or, rather, flows through the system. As one set of processes or treatment finishes another clicks into place immediately.
The Bolton Hospitals and NHS trust has also enjoyed some dramatic changes which have been made to its accident and emergency department and pathology lab, which now operates in half the space it used previously.
As with the Virginia Mason hospital, Bolton has used the kaikaku technique for implementing rapid change. These multi-disciplinary workshops aim to fix a problem in just five days with the new system up and running by the following Monday.
The way it works is quite simple. On the first Monday, a team made up of the department under review, for example radiology, and members from various departments immediately before and after in the supply chain, get together and map the current processes.
The next day, the ideal future state map is drawn up with all wastes identified and removed leaving the following days free for implementation strategies. The idea is that by Friday all the problems will have been solved and a new method of working will have been discovered and implemented ready to begin the following week.
When redesigning the blood science laboratory at Bolton, the team even invaded the hospital's car park and used cardboard cut-outs of the equipment to map their ideal positions in the lab. They have managed to decrease the number of physical steps it now takes a technician to process a patient's blood sample. Fewer steps equal less walking time, which means a speedier service. Consequently, blood sample turnaround times have dropped by 90 per cent.
· Which techniques/tools of lean can you identify in the stories of Virginia Mason and Bolton Hospitals?
· What are the potential benefits of lean within healthcare? Dangers?
· “A Carmaker As A Model For A Hospital?”, John Blackstone, CBS Evening News, June 9, 2009, (http://www.cbsnews.com/stories/2009/06/06/eveningnews/main5068218.shtml)