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The Lean Hospital

From: The Hospitalist, June 2008

More facilities using Toyota methods to improve every step of care from inventory to discharge

by Carol Berczuk

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

A Lean Discharge Case Study

Waiting to be discharged from the hospital is frustrating for patients and costly for hospitals.

At the University of Michigan Medical Center in Ann Arbor, the discharge process was taking too long, according to Christopher Kim, MD, a hospitalist there.

Discharge was a three-step process. First, physicians had to write discharge orders. Next, clerks had to prepare them. Finally, nurses had to give patients their discharge instructions. It was a formula for lots of waiting time—“waste” in lean terminology.

The lean team “found that everything was happening in a serial basis,” Dr. Kim recalls. “Clerks would only write orders when the physicians finished and the nurses would not do anything until clerks finished.”

Physicians often would tell their patients they were to be discharged but fail to inform the nurses. “Nurses would find out from the patients,” Dr. Kim says. It was sometimes hours before the physicians got around to writing up the orders. No orders meant no paperwork. No paperwork meant no nurse-patient instructions. One bottleneck would delay the entire process.

The lean team instituted a parallel procedure. Now, Dr. Kim says, “Discharge order slips are available at the patient’s bedside.” Those forms go directly to the clerks, who notify the nurses, who then begin their discharge instructions. In theory, no one is waiting for anyone else to finish one job before starting another.

In practice, discharge time has decreased from about 195 minutes to 89, a 54% reduction. Knowing early how many beds will become available each day has “also eased the backlog of patients in the ER trying to get into beds and offloads workloads at those places,” Dr. Kim says.

There still is room for improvement. “It’s still a work in progress,” Dr. Kim admits. “We’re still working on our doctors to write their orders even sooner. That’s our next goal.”—CB

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Time-motion studies of the operating room at LeBonheur Children’s Medical Center, Memphis, Tenn., revealed a chaotic inventory system. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time—and saved $243,828.

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.


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