Lean in Healthcare

Daniel T Jones, Founding Chairman, Lean Enterprise Academy, UK.

"The difference between lean and the previous methods is that lean focuses on the entire healthcare process itself whereas traditionally healthcare has focused on separately scheduled individual activities."

What benefits does lean bring to the healthcare organizations vis-à-vis the older models of functioning?

The benefits of lean for healthcare organizations are that firstly, the quality of the outcomes in terms of mistakes and errors improves. The second is that the amount of time taken through the whole process significantly improves as a result the number of patients that can be put through the process increases i.e. the productivity or throughput of the process increases. While the initial gains come in terms of improved quality, reliability of the process and elimination of a lot of wastes associated with the process. The medium term gains come in the form of a significant increase in the throughput of the process. It improves Quality, Reliability and Productivity of a process; and it does so while making work easier for the medical staff by removing a lot waste and improving the customer experience as well. So actually this is a winwin opportunity for improving quality of healthcare, delivery of healthcare and the productivity of the staff. These gains are realized by focusing on the entire sequence of steps instead of individual activities.

The medical process is very much geared to the event where the patient and the doctor actually sit together, whereas if you look at the actual sequence of events, there is a tremendous amount of unnecessary activity that goes on because of lots of delays, repeat tests and events not occurring in the right sequence. So lean really focuses on the patient’s journey on the one hand and the medical process that goes to make the journey possible.

So lean reduces the time taken by the patient to go through the process of treatment…

Time taken by the patient as well as the provider to deal with the patient. So there are two parallel processes going on: one is the patient itself and the other is the activities that have to happen in terms of the scheduling, maintaining the records, conducting the tests and so on. These are streamlined better by implementation of lean. The difference between lean and the previous methods is that lean focuses on the entire healthcare process itself whereas traditionally healthcare has focused on separately scheduled individual activities.

Do the benefits outweigh the costs?

Almost certainly, yes. The costs are initially an involvement of staff in coming together to look at and analyse the current process and improve it. So there is an investment in time of the staff in actually looking together at the whole process and then going through several redesign activities. However, the experience is that this is very quickly paid back by the improvements in the performance of the system. Initial gains can come within a few weeks of implementation but the real gains come in a period of eighteen months to two years, largely in terms of increased throughput with existing resources which means that you don’t need to invest in additional capacity, equipment and people. And that’s the typical situation being faced by healthcare organizations, there’s more demand than they can keep up with. So lean really helps save both in terms of current costs and capital costs. While this is in terms of costs, in terms of staff morale, it has a very dramatic effect because people suddenly feel engaged in improving the way they work.

What steps does an organization need to take in order to implement lean?

There are various ways organizations have gone about implementing lean but any organization certainly needs to build a small group of staff, a lean team so to say, who first of all understand lean and then take responsibility for leading activities to look at individual processes. The team needs to involve the clinicians, nursing staff and the management. Having done that, they need to pick key processes that are in trouble and begin to analyse them and engage the people involved. The key here is to build some kind of internal knowledge. Therefore, though the implementation of lean begins at the top level of the hierarchy it needs to be quickly passed down to the bottom. It's top down in the sense that the initiative must be supported by the top management but the actual implementation has to involve the people right at the frontline since they are the people who know exactly what’s wrong with the current processes.

What kind of penetration has lean achieved in the healthcare sector?

Lean has been taken up in the healthcare sector only in the last two or three years. In the US several hospitals got involved in try-and-apply lean by hiring Toyota experts and experimenting with how lean applies to healthcare. In the UK, the UK NHS modernization agency began work on applying lean to the accident and emergency department and cancer treatment about three years ago. In Australia they started about two years ago. So in those three countries it has already begun and they were initially really experiments where different hospitals tried to translate the idea into language of healthcare from a language of manufacturing.

But in the last year, especially in Australia and UK, the interest has suddenly become huge and it has certainly now become a big wave and we are getting interest from several other countries as well such as Germany, Holland, Denmark and of course, Asian countries as well. The best example in the Asia-Pacific region is the Flinders Medical Centre in Adelaide. They held the first redesigning healthcare conference last march that attracted over 300 people from countries like Australia, New Zealand and Singapore. So these ideas are trickling everywhere in healthcare. However, it is fair to say that we are still in the early stages of working out what the full impact of lean on healthcare is. We don’t yet have a possibility of pointing at a hospital and saying “here is a truly lean hospital.” I think we are still two or three years away from that.

I started walking around hospitals around six years ago because I thought this would come. I thought I needed to understand how the healthcare system works. But it was too early. People were not really focused on the customer and were worried about quality rather than efficiency.

What challenges does the implementation of lean bring?

Initially it probably doesn’t change the organization a great deal but gradually as you start separating out the different flows of the hospital and start seeing the hospital as a collection of different flows — a short stay flow, a long stay flow, an out-patients flow rather than a series of departments, what you begin to see is a change in the orientation of the hospital, where the departments are increasingly supporting different flows rather than just managing their own activities. And you begin to see much better coordination and somebody taking responsibility for coordinating each of these different flows across departments. Therefore, a process focus as well as an activity focus begins to appear. In terms of psychological change, this releases a tremendous amount of energy. And if done well it can actually change the psychological atmosphere of the organization because people feel less stress and pressure and begin to achieve much greater results than they actually thought possible.

How valid are the criticisms of lean, like, it doesn’t consider the human factor?

Actually, you can’t consider going lean without taking the human factor into consideration because lean depends upon people in the process who are willingly cooperating to improve the process. If lean is badly managed or is simply used as a tool for pressurizing people it will go backwards very quickly; people will stop collaborating. It’s very difficult to misuse lean as people get to see what you are doing and they will not be willing to cooperate. I know that there have been lots of criticisms of lean and look, not every lean implementation succeeds. Lean is quite hard and it sometimes goes forward and sometimes reaches a plateau, people leave, organizations change and you may have to go backwards again. In general, lean is a very positive step for an organization.

What are the limitations of lean with respect to its application in healthcare?

I think we are still experimenting with what lean is going to mean. I think lean in the future is going to mean we will design our healthcare processes very differently. And quite possibly, some of the things we do in the hospitals might well be done down closer to the patients in what we call primary care. Some of the more routine activities can certainly be done by nurses closer to patients but we need smaller scale equipment to help them do that while at the moment people are building bigger and bigger and more expensive machines.

Would it be easier for a new hospital to implement lean than an older hospital?

Theoretically yes. The knowledge of turning around an existing hospital is quite struggle and it takes time but I don’t think it's necessary to start with a clean sheet.

Any other comments?

I think we are at the starting of a revolution in healthcare in the way healthcare is delivered and lean is an important trigger in doing that. I think it will lead to all sorts of new thoughts about how healthcare is delivered in the future. And we need to engage the pharmaceutical companies, the medical equipment companies as well as the hospitals and governments in thinking that through. The really exciting prospect in the future is that we design systems fundamentally from customer backwards rather than trying to keep a big hospital busy.

Author Bio

Daniel T Jones

Daniel T Jones, Founding Chairman, Lean Enterprise Academy, UK.