Lean Hospitals

Improving Quality, Patient Safety, and Employee Engagement, Third Edition

Mark Graban

• Publisher: Productivity Press
• Year: 2018
• ISBN:
  9781315352015
• Edition: 3
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Organizations around the world are using Lean to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems. Lean Hospitals, Third Edition explains how to use the Lean methodology and mindsets to improve safety, quality, access, and morale while reducing costs, increasing capacity, and strengthening the long-term bottom line.This updated edition of a Shingo Research Award recipient begins with an overview of Lean methods. It explains how Lean practices can help reduce various frustrations for caregivers, prevent delays and harm for patients, and improve the long-term health of your organization.The second edition of this book presented new material on identifying waste, A3 problem solving, engaging employees in continuous improvement, and strategy deployment. This third edition adds new sections on structured Lean problem solving methods (including Toyota Kata), Lean Design, and other topics. Additional examples, case studies, and explanations are also included throughout the book.Mark Graban is also the co-author, with Joe Swartz, of the book Healthcare Kaizen: Engaging Frontline Staff in Sustainable Continuous Improvements, which is also a Shingo Research Award recipient. Mark and Joe also wrote The Executive's Guide to Healthcare Kaizen.

Chapter 1

The Need for Lean Hospitals

Better Results with Lean

“Lean” is a process improvement methodology and, more importantly, Lean is a leadership style and a management system. Lean has been embraced by hospitals and health systems since the 1990s, especially so in the past 10 years. The Lean approach is powerful, but it is not a quick fix. Lean promotes a new way of thinking and a different organizational culture, requiring change and participation from everybody at all levels. The practical methods and tools used within this broader framework have led to measurably better performance in areas such as patient safety, quality, waiting times, cost, and employee morale in healthcare organizations around the world.

Lean is not something you simply implement this year or in a few short years. Lean is an approach that you practice diligently, improving and learning more over time. Lean doesn’t mean being perfect or completely free of waste, since no organization ever reaches those heights. But a “Lean hospital” is one where leaders have a humble, inquisitive mindset and a management style that allows for the reinvention of aspects of healthcare delivery and creates a culture of continuous improvement.

Why Do Hospitals Need Lean?

Taiichi Ohno, one of the creators of the Toyota Production System, wrote that organizations must “start from need” and that “needs and opportunities are always there.”¹ In 2014, John Shook, CEO of the Lean Enterprise Institute and the first American to work for Toyota in Japan, said we should start by asking, “What is the purpose of the change and what problem are we trying to solve?”² John Toussaint, MD, former CEO at ThedaCare (Wisconsin), emphasizes that Lean activity must be “focused on a … problem that is important to the organization.”³

Today, the need for Lean in healthcare is very clear in terms of underperforming performance metrics and general dissatisfaction. Hospitals face a growing number of external pressures and challenges as well. Hospitals do many wonderful things, including saving lives. But, a senior leader at a prestigious university hospital summarized their internal challenges by lamenting that “we have world-class doctors, world-class treatment, and completely broken processes.”

So, how can an approach called Lean help healthcare organizations? On first hearing the word, people might complain that they are already understaffed and do not have enough resources. Of course, being Lean means having the right staffing levels and resources to do quality work in a way that’s not too stressful. The everyday use of the term lean and countless newspaper headlines reinforce what are often negative connotations about not having enough resources. Rest assured, the approach presented here is not about mass layoffs. Lean is very different from traditional “cost-cutting” methods that have been tried in multiple industries, including healthcare. The idea of “preventable” errors may also bring skepticism, as employees and physicians believe they are already being as careful as possible. Hospitals using Lean methods do not improve quality by asking people to be more careful any more than they improve productivity by asking people to run around faster.

Lean is a tool set, a management system, and a philosophy that can change the way hospitals are organized and managed. Lean is a methodology that allows hospitals to improve the quality of care for patients by reducing errors and waiting times, which also results in lower costs. Lean is an approach that supports employees and physicians, eliminating roadblocks and allowing them to focus on providing care. Lean is a system for strengthening hospital organizations for the long term—reducing costs and risks while also facilitating growth and expansion. Lean helps break down barriers between disconnected departmental “silos,” allowing different hospital departments (and sites within a health system) to better work together for the benefit of patients.

How a Lean health system respects and supports staff:

▪ Focuses on their safety and well-being

▪ Ensures people have what they need to do the work

▪ Doesn’t put people in a broken process

▪ Doesn’t drive cost-cutting through layoffs

▪ Doesn’t overburden people

▪ Has proper staffing levels

▪ Gives help and support when needed

▪ Doesn’t blame people for systemic errors

▪ Lets people do meaningful work

▪ Lets staff work to their level of licensure

▪ Listens and engages people in improvement

Someone might ask how Lean methods can help solve the everyday, nagging problems that so many committees and teams have already tried fixing. Lean is not a silver bullet, but it is different in that people learn how to look at the details of processes instead of jumping through the same proverbial hoops every day. The people who do the work help fix things where the work is actually done, instead of relying on experts to tell them what to do. Lean helps leaders see and understand that it is not the individuals who are broken, but the system itself. This happens in a way in which the system can actually be fixed, improved, or reinvented in small, manageable bites, with managers and staff working together. The Lean approach also requires the continued learning and professional development of employees, for their own sake and the sake of the organization.

A Renewed Sense of Purpose

People in healthcare are driven by an important mission and a strong sense of purpose. The everyday problems, waste, and broken processes interfere with what healthcare providers and employees want to do: provide the best possible care to patients and keep people healthy. These problems can also leave people short on time, interfering with their ability to provide a caring environment for their clinical care.

Dr. Jacob Caron, an orthopedic surgeon and former chief of the medical staff at St. Elisabeth Hospital (Tilburg, the Netherlands), is one of their leading advocates for Lean. During a 2009 presentation at a Dutch Lean healthcare symposium, his title slide read, “Lean and Loving … a mission impossible?” To hospitals like St. Elisabeth, an important motivation for reducing waste is to free up time for clinicians. This newly found time is used not only for better clinical care and improved responsiveness to patient requests but also for what St. Elisabeth describes as “loving care.”⁴ When nurses are not scrambling to find supplies and medications, they can take time to talk with patients, answering questions and alleviating anxiety they might have about their hospital stay. In 2015, Dr. Caron said, “Our quest has developed further in a growth process for our coworkers and ourselves. Lean still influences my work as orthopaedic surgeon and medical specialist on quality and safety, as well as my behavior as a person.”⁵ The combination of efficiency and caring has led to results including orthopedic waiting times being reduced from “several months to four weeks.”⁶

Lean Methods Are Not New to Healthcare

While Lean has been used formally in healthcare for a relatively short time, industrial engineering (often known as management engineering in healthcare) has been used for a century to improve hospitals.

Frank and Lillian Gilbreth, sometimes known from the original 1950 version of the film Cheaper by the Dozen, were two of the original “efficiency experts” of the late nineteenth and early twentieth centuries, with many of their methods influencing the later development of Lean. Outside of their primary factory work, the Gilbreths published many studies in medicine, being among the first to demonstrate that industrial engineering methods could be applied to hospitals. One innovation from the Gilbreth studies was a practice we take for granted today—having a surgical nurse hand instruments to surgeons as called for, instead of the surgeon taking time away from the patient to search for them and retrieve them.⁷

In 1922, Henry Ford wrote about efforts to apply his production methods to a hospital in Dearborn, Michigan. Ford said, “It is not at all certain whether hospitals as they are now managed exist for patients or for doctors. … It has been an aim of our hospital to cut away from all of these practices and to put the interest of the patient first. … In the ordinary hospital the nurses must make useless steps. More of their time is spent in walking than in caring for the patient. This hospital is designed to save steps. Each floor is complete in itself, and just as in the factories we have tried to eliminate the necessity for waste motion, so we have tried to eliminate waste motion in the hospital.”⁸

Almost a century later, nurses around the world still spend more time dealing with waste in the workplace than they spend at the bedside—until Lean is employed to help. This long history suggests that there are long-standing systemic problems in healthcare that have not been solved by old approaches. Virginia Mason Medical Center (Seattle, Washington) has increased the amount of time that nurses are able to spend at the bedside from 40% to almost 90%, which improves job satisfaction and patient care.⁹

Toyota’s Role in Popularizing Lean

Toyota Motor Corporation is sometimes known as “the company that invented Lean production.”¹⁰ Toyota developed the Toyota Production System over many decades, starting in 1945.¹¹ Inventing and refining a new production system was not an overnight success story, nor will be your hospital’s Lean transformation, as changing old mindsets and organizational cultures takes time. Saying that Toyota “invented” Lean is not exactly accurate, as Toyota learned from and was inspired by many others, such as the writings of Henry Ford, the nineteenth-century Scottish self-help author Samuel Smiles, and the restocking practices of American supermarkets.¹² Toyota was also heavily influenced by the visits of Dr. W. Edwards Deming, as the president of Toyota said in 1991, “There is not a day I don’t think about what Dr. Deming meant to us. Deming is the core of our management.”¹³

Toyota took some aspects of the Ford approach, but created its own management system, using and inventing methods that fit its needs and situation. In 1945, Toyota set out to improve quality, while improving productivity and reducing costs, as the company was very cash poor and had a small Japanese market in which to sell cars. Crisis and hardship forced Toyota to be creative and innovative; it did not set out to create a production system per se. Toyota was focused on improving its business, and that turned into a management system that became the way they conduct business every day, as opposed to being a short-term program. It is critical for hospitals to follow Toyota’s model of adapting what you learn from others and developing methods that solve the problems in your organization, without blindly copying the practices of factories or other hospitals. Lean is a ne...