During one of my first consulting engagements, my client had a penchant for veering off topic. So naturally when she brought up her black belt in Lean Six Sigma, I assumed she was about to share her interests in martial arts. During my time in the hospital as a medical student and surgical resident, I had never heard of Lean processes, let alone Lean Six Sigma. Although the concept of Lean production has been around since the automobile companies introduced it in the 1950s, it has only recently gained traction in the healthcare industry. Even five years ago, the idea of eliminating excessive or duplicate resources seemed to contradict the concept of protecting oneself from a legal standpoint. It didn’t matter if the patient had already answered questions about his medical history —I needed to ask him again and document what I heard. It didn’t matter that the patient brought copies of tests from another hospital—we needed to redo them so they would be in our system. The healthcare industry can learn a lot from the auto industry. Both building a car and caring for a patient involve multiple complex processes, and a waste of time or money must be recognized as decreasing the end value.
Adopting Lean’s approach of targeting waste can easily be done at an individual level. As bottom lines are being squeezed, hospitals are pursuing low-hanging fruit by adopting Lean processes at an institutional level. The real value, however, comes from a shift at an industry-wide level. The incentives laid out in the American Recovery and Reinvestment Act (ARRA) for medical providers to switch from paper charts to electronic records are helpful first steps, but having the data is not enough—we need to do something with it. Bill Owad, senior VP of Operational Excellence at Cardinal Health, sees a large opportunity for implementing Lean techniques in the hospital. He believes that by looking at the variation in care along with eliminating the duplication of events and tests during the patient experience, a hospital can easily reduce costs by 5%. “It’s all about connecting end to end the chain of care, making sure the information moves effectively and that cost-effective solutions are offered at all points,” says Owad.
Although Lean is still in its infancy in healthcare, there have already been case studies showing promising results. The Robert Wood Johnson University Hospital Emergency Department, a level 1 trauma center in New Brunswick, NJ, sees approximately 75,000 patients per year. In 2010, it was a prime candidate for Lean transformation due to the usual challenges of increased demand, overcrowding and long wait times. Teams of nurses, physicians, critical care technicians and unit secretaries were assembled and charged with the re-evaluation of core emergency department (ED) work processes and overall work flow from a patient’s admission to discharge. The initiative focused on two key inefficiencies—supply inventory management and demand management. To tackle the first, the teams assessed the ED supply inventory, reordering systems and proximity of supplies to the point of care. This revealed “too few supply locations, unorganized and expired supplies, excess inventory and unacceptable distance between supplies and the point of use.” Demand management was addressed by using a full-capacity protocol—when low-risk patients are boarded out of the ED. Additionally, two years of data on patient arrivals, patient holds and current staffing patterns were analyzed. Preliminary data has revealed that by utilizing lean principals to address these inefficiencies, the average patient’s length of stay was reduced by 47 minutes— significant considering the national average is just over four hours.
As the implementation of the Affordable Care Act (ACA) is transforming the healthcare landscape, it is an opportune time to borrow Lean principles from the domain of cars and expand their use in any new or revised processes in hospitals. I’m reminded by a joke comparing the two worlds:
A mechanic was removing a cylinder-head from a car motor when he spots a well-known surgeon walking into his shop. He yells across the floor, “Hey Doc, can I ask you something?” The surgeon, a bit surprised, walks over to the mechanic. The mechanic wipes his hands with a rag and says, “So Doc, look at this engine. Just like you, I open its heart, take out the valves, fix ’em and put ’em back in, like new. But, how come you get the big bucks when I’m barely scraping by?” The surgeon pauses, smiles, leans over, and whispers to the mechanic…”Try doing it with the engine running.”
Although many would agree that caring for the human body is much more complicated than car manufacturing, this shouldn’t prevent the transfer of basic concepts. If anything, the unique, life-touching nature of healthcare demands the widespread use of proven Lean methods found elsewhere.