Lean Method, a Solution to Problem in Hospital

Lean Method, a Solution to Problem in Hospital Sfandyarifard, E. The University of Salford, UK (email: e.sfandyarifard@pgr.salford.ac.uk) Abstract It is becoming increasingly difficult to ignore the importance of appropriate building in which healthcare can be delivered. There is already a program with the purpose of improving existing primary, community and secondary healthcare buildings across the country. In addition to that, National Health Service (NHS) is undergoing a transformation from a centralized organisation into a network of collaborating and competing health service providers. The design of health service traditionally is based on a transformation model concept. In this concept the functional areas are central and the emphasis is on clinical specialties. Each department has its own physical space, budgets, employees, and management structures. The emphasis of this concept is on functions, which transform inputs into outputs. Each department has effect in the overall patient experience and care. Despite having significant progress based on this model, over the last few years, which has been made by NHS, more improvements are needed. Poor safety and quality, capacity constraints and queues, cash-flow crises, low levels of efficiency and low levels of staff motivation in hospitals are as a result of traditional systems. It is possible to tackle all these problems at the same time under the umbrella of Lean Healthcare. The aim of Lean concept is to reduce waste and maximise value, enabling increased patient satisfaction through redesigning and streamlining services. The aim of this paper is to applying Lean method as a solution to the problems of the hospital environment. The study began with a review of relevant materials from textbooks, journals, conference papers, and Internet information to capture the background of Lean principles. It is then accompanied by examples of implementation of this method in the hospital environment. At one hand, Lean can improve safety and quality, on the other hand, improve staff morale and reduce costs. The Lean message is 100 per cent positive; through releasing human potential it can add value to patient care and consequently improve quality. It can create a virtuous circle rather than perpetuating vicious ones. Keywords: Hospital environment, Lean hospital, Lean method 648

1. Introduction It is becoming increasingly difficult to ignore the importance of appropriate building in which healthcare can be delivered (Ulrich et al., 2004). Lean is a toolset, 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. Lean is an approach that can support 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 to better. (Graban, 2009.pg 1) The aim of this paper is to applying Lean method as a solution to the problems of the hospital environment. This paper starts by explaining brief rehearsal of the Lean principle, looking at the importance of value versus waste, noting the essential role of standard work and giving examples of the various tools of lean. 2. Research method According to Hart (1998, pp.13) the literature review is the selection of available documents (both published and unpublished) on the topic, which contain information, ideas, data and evidence written from a particular standpoint to fulfil certain aims or express certain views on the nature of the topic and how it is to be investigated, and the effective evaluation of these documents in relation to the research being proposed The advantages of the literature review are : providing researchers the knowledge required to narrow the focus of their research topic, specifying the research problem in detail, identifying gaps in existing research knowledge, learning how to express certain views on the nature of the topic, identifying of neglected issues in previous researches, getting a rich source of secondary evidence on which to outline and finally creating a summary of research evidence(burns,1997, pp.27-29). The study began with a review of relevant materials from textbooks, journals, conference papers, and Internet information to capture the background of Lean principles. It is then accompanied by examples of implementation of this method in the hospital environment. 3. The 5 Principles of lean The book Lean Thinking defines the term as follows: In short, lean thinking is lean, because it provides a way to do more and more with less and less less human effort, less equipment, less time, and less space while coming closer and closer to providing customers with exactly what they want. (Womack and Jones, 2003) According to Womack and Jones (2003), the five principles of Lean can be described as follows: 1. Specify value from the customer s perspective. 2. Identify and define the value stream 649

3. Make the value process flow. 4. Let work and supplies be pulled by the customer 5. Pursue for perfection through supply the customer needs continually The five principles of Lean thinking, which should be described for hospitals, are summerised in Table1. In the field of healthcare, there might be many customers. The most obvious one is the patient and other customers could be the patient s family, hospital employees, physicians, and payers. Value could have different meaning to different costumers. The existence of an internal costumer in any process is probable. Therefore, the person who is doing the work should be aware of the importance and effect of his work on ultimate end customers. The work should also be performed in such way that allows the downstream recipient of the work to play as an effective in the total patient care system. In Lean, the costumer s viewpoint defines the value of the output of a process. Therefore, following criteria are essential to consider an activity as value-added (Sayer et al, 2007). The customer must be willing to pay for the activity. The activity must transform the product or service in some way. The activity must be done correctly the first time. Table.1 Principle Lean Thinking Principles for Hospitals Lean Hospitals Must: Value Specify value from the patient s perspective Value stream Flow Pull Identify all the value-added steps and eliminating steps that do not create value. Keep the process flowing smoothly by eliminating causes of delay, such as batches and quality problems. Avoid pushing work on the next department; let work be pulled by the customer. Perfection Pursue perfection through continuous improvement. Source: Adapted from Lean Enterprise Institute, Principles of Lean, http://www.lean.org/whatslean/principles.cfm (accessed April 20, 2009) 650

4. Seven wastes According to Ohno seven types of waste have been identified (Liker, 2004). In the field of healthcare, waste means all activity that adds cost but not value. The first step is to recognise the existing waste and followed by elimination as the next target. The different types of waste in the hospital environment are shown in table.2 and will be discussed in following section. 4.1 Waste of defects The work activities in hospitals that are not done right the first time or Defects can cause injury or death. According to the Institute of Medicine, the estimated 400,000 preventable drugrelated injuries take place each year (Graban, 2009); which can be assigned as defect, with extra consequences such as illegible handwriting, misplaced decimal points, or defects in the process for getting medications to the patient. For example, three babies died due to wrong level doses of heparin in the newborn intensive care unit of Methodist Hospital (Indianapolis, Indiana). (Davies, Tom, 2006) The incident was a result of a series of process defects, including the stocking of adult doses of heparin by a pharmacytech in the newborn ICU drug cabinet. In another process defect, nurses mistake in administrating the right dose medicines in newborn ICU. A number of process defects, miscommunications, led to this incident and no single person is responsible for the whole event or the failure. However, being concentrated on the overall process dose not mean that no one is liable for the failure and the incident and the workers should still be held accountable. A defect does not necessarily have to cause harm and can include things that go wrong that lead to rework or workarounds. It can even be a slowing he product of patient specimen and test result, which results in the waste of the labor time for the employees. Process defects include things that go wrong and lead to rework or workarounds. 4.2 Waste of overproduction The Waste of Overproduction is defined as; if production is phased ahead of schedule, either producing too much of a product or producing earlier than it is needed by the customer. For example, the medicines produced by the pharmacy in one hospital for nurses and patients should be made and/or delivered in an appropriate time. If it is delivered too early, it can be considered overproduction as it may be returned back to pharmacy. 651

4.3 Waste of transportation The waste of transportation can be defined as the movement of components and materials on around a site. Double handling is a waste that affects both productivity and quality. Therefore, in the long term we might rearrange the elements of the hospital to reduce the transportation distance for patients or specimens. Moreover, the use of our understanding about the transportation waste during the design and construction phases of a new hospital can be so useful and effective. As an example, in one hospital a 74-year-old woman during the course of her visit for a procedure would walk the equivalent of 5½ football fields. In order to reduce the waste, the hospital decided to implement the Lean method and redesign more carefully through taking patient walking distances into account. 4.4 Waste of waiting Waiting time can be defined, as a time when nothing is happening or, it is not being used effectively. Patients wait during their care procedures in their patient pathway. Systemic problems or uneven workloads can also cause the employees to wait. Lean methods can be used in order to reduce the waste of waiting in both cases. Due to poor flow or poor scheduling, patients often wait for appointments in different hospital units such as physician clinics. As well as patients, other physical products such as tubes of blood, pharmacy orders and medications also spend a considerable amount of time waiting instead of being used more effectively - valueadded work. The waiting is the enemy of smooth flow and is mostly as a result of batching within different units and departments, poor scheduling and the waiting on employees who have more than one responsibility. Process defects, delays in upstream processes, uneven workloads, and low patient volumes are the common causes of employee wait. This waiting time can be replaced with productive activities, such as cleaning, maintaining, checking, and even deliberate relaxation. In order to improve quality and productivity, time management is required to develop a contingency plan for the best use of time. 652

4.5 Waste of unnecessary inventory The waste of unnecessary inventory is seen as the enemy of quality and productivity and refers to having more inventory than is needed. It results in increase lead-time, prevents rapid identification of problems and increase space thereby discouraging communication. In hospital excessive inventory waste could be seen in; bed assignments, pharmacy stock, lab supplies, samples, specimens waiting analysis, paperwork in the process and patients in beds. Excess inventory that may be expirable, such as supplies and medications or simply kept on shelves can harm hospitals in different ways. Moreover, the primary goal of the Lean is not just keeping the inventory level low, but it should aim to take care of the patient and costumer needs and then try to keep the inventory in the lowest possible level. In a Lean environment, through appropriate supply and inventory system the given patient care is maximised while the cost and waste for the hospital are minimised. 4.6 Waste of motion The waste of transportation was referred to the product and the waste of unnecessary movement is related to employees. Some of the benefits of reducing this waste could be; reducing the physical fatigue of employees or having more time for value-added work. Some examples of the waste of motion could be searching for patients, meds and charts, gathering tools and supplies and handling paperwork. According to Graban (2009), unnecessary walking is the main source of wasted motion in a hospital setting, which could be reduced by providing a better layout and organization of supplies and equipment. 4.7 Waste of inappropriate processing This form of waste refers to use larger scale equipment than required by the customer. For example, in the laboratory, in order to analayse many blood specimens they should be centrifuged. The blood will be separated into its components in a particular time that after this time the remaining blood has no value and no additional information. As a common habit among the staff, the time set for centrifuges are longer than recommended required. Examples of the waste of inappropriate processing include: Multiple bed moves 653

Retesting Excessive paperwork Unnecessary procedures Multiple testing 4.8 The waste of human potential or talent The waste of human potential or talent is the eighth type of waste, which is not mentioned in Lean literature and other suggested it. Highly skilled employees potential will be wasted when they have to search for supplies, as we are not getting the most out of their. Lean aims to include following roles: managing, leading, developing, and inspiring people and not just about managing supplies or any particular processes. Bodek, (2004, pg 115) describes it as a waste of not utilizing the talent inherent in your workers which could injures patients, the employee and also the organisation. 5. Essential non-value-added activities There are some necessary activities under the current processes, which are called Essential Non- Value-Added activities and should be removed through a major improvement. In the field of healthcare, a good example could be employees walking activities. Walk to a medicine cart or walk between far ends of the unit. Relocating the medicine cart or adding a second cart and clustering all of a nurse s patients together in adjoining rooms could be a solution to reduce the need to walk more. One of the most common discussions about value-added or non-value-added activity comes from quality inspections. The medication administration process has multiple inspection steps, such as (Graban, 2009): Pharmacists verifying prescriptions for proper dosing and interactions Pharmacists double-checking the work of pharmacy technicians who pulled medications to match the order Nurses double-checking that the right medication is being given to the right patient 654

In the Lean concept these inspection steps are necessary if the existing process is not perfect. So Lean recognised all these inspection steps as a NVA. From the Lean perspective, it should be necessary to find a way to have a process without errors instead of using inspections or double-checks to find them after the fact. However, the inspection steps should not be eliminated until the error proofing be deemed 100% effective, to protect the patients. 6. Non-value-added Some non-value-added activities just take up time, space and utilise resources and are so unproductive, which are wastes. In a hospital environment, non-value-added activities could be process defects, waiting time or time spent dealing with errors. Recognising time spent dealing with errors as a none-value-added activity does not mean that employees should avoid fixing problems. It however, should be focused on improvement and prevention. Some examples of VA and NVA activity for different departments in a hospital are shown in Table 3. Table.3 examples of VA and NVA activities Department VA Activity NVA Activity Emergency room Clinical laboratory Being evaluated or treated Being centrifuged or tested Interpreting a test result Waiting to be seen Waiting to be moved as a batch Fixing a broken instrument Pharmacy Medication being formulated or prepared Creating an IV formulation Being inspected multiple times Creating an IV formulation Operating room Operating on patient Waiting for delayed procedure or performing unnecessary steps Inpatient unit Administering medications to a patient Copying information from one computer system into another Radiology Performing MRI procedure Performing a medically unnecessary scan 655

7. Standardized work Most communication about process changes on job instructions and policies in hospitals are often occurs in informal ways such as posted signs and verbal handoff communications. The discordant of signs can be easily missed by employees in a hospital which is a dynamic environments operated with many peoples. In order to improve and manage the communication methods and the way that we do the work, the work system should be standardised based on Lean practices. 7.1 Types of Standardized Work Documents In practice there is no single format of standardized work documents and many types of them can fit different situations. As it can be seen in table.4, some of the common formats in standardised work systems are listed, with examples of their application in a hospital. Table.4 Types of Standardized Work Documents Tool or Document Purpose Hospital Example Standardized work chart Work combination sheet Primary document that shows job responsibilities, common work tasks, and how long they should take; often shows a diagram of where work is done Analyzes relationships between an operator and a machine to synchronize work and eliminate operator waiting time; used to determine how multiple people could divide that work Daily routine for lab employees, nurses, pharmacy employees Clinical laboratory core cell automated area Process capacity sheet Analyze capacity of equipment, rooms, other resources; considers changeover or set time and other planned downtime Analyzing OR capacity and changeover time Operator work instructions Source: Adapted from Lean Hospital Details important cyclical and noncyclical tasks, used as a reference or training document, and is not posted in the work area; describes key points for quality and safety Clinical laboratory core cell; pharmacy technician duties for responding to first dose orders In some cases the detailed work instructions have been made as job guidance sheets to indicate the level of detail, task, sequence, timing and key points that are important in 656

health and safety of the work. These documents are posted in the workplaces and can be used as a reference or as a checklist to ensure the correct performance of the steps. Depending on our particular situation the exact format of standardized work documents, as with other Lean practices, can be adopted and applied. 8. Lean methods In order to convert the philosophy and concept into action the technical tools, which simply are just one component of the integrated system of Lean can be used and would be very necessary to eliminate waste. This chapter will focus on some of the hospital-specific examples of the use of visual management and 5S. 8.1 Reducing waste through visual management The visual management is another form of standardised work, which aims to illustrate the waste and problems related to employees and managers and fix them instead of hiding them. Reducing the information deficits in the workplace is the main purpose of visual management from Gwendolyn Galsworth perspective (2005). Also she mentioned that a lot of similar questions are asked by people or even some just made up. (Ibid) It happens also in the hospital environment due to lack of information, which do not exist or is not readily apparent thus the need for visual management. As an example, some of the children in the radiology department of one children s hospital are appointed for multiple imaging diagnostics, such as a sonogram and an MRI. As employees can only see the schedule for their modality, it is common some patients leave without having their second imaging completed. Consequently, this will result in wasting equipment time, transportation and time for the patient and parents and also reworking for the scheduling employees. The visual management tool was used in this case to eliminate the wastes and reworking by the staff; the front desk staff of the radiology department s, attach two laminated color-coded cards to the patients shirt who have two modalities to visit. This will remind the first modality s staff that the patient need go for the second procedure and consequently the team took a more simple, effective and visual plan to overcome that information deficit. 657

8.2 5S: Sort, Store, Shine, Standardize, and Sustain In order to reduce waste by improving workplace organization and visual management, the 5S methodology can be used. Implementing 5S is more than just a neat and orderly looking workplace, as John Touissant, CEO of ThedaCare Health System (Wisconsin), evaluated that this methodology (5S) improvements had reduced the amount of wasted time from 3.5 hours a day to just 1 hour per day in an average s 8-hour shift of a nurse.( Touissant, 2007) The 5S concept takes its name from the origins of the method in five Japanese words beginning with the letter S which can be either translated into 5 English S words. 8.2.1 Sort The first stage of five is Sort which aims to remove items or equipment that are no longer needed. As an example, in one laboratory, the team who work on the sorting activity, found some items such as expired reagents or slides dating back many decades, broken centrifuge or microscopes or tubes that expired months ago in the bottom of drawers. By removing the unneeded items, the excess construction and maintenance costs will be reduced and also the broken equipment and expired supplies can be used for value-added activities (5S for Operators). A buffer zone is placed for the items that might be needed in the department to allow everyone have a look at the items which team was deciding to throw away(galsworth, 2005). 8.2.2 Straighten The next step of 5s is properly organising the items and equipments that remain. Items and equipments should be kept in the closest to the point of use and in the multiple storage points if used by multiple people. 8.2.3 Shine The third S of 5s focuses on the cleanliness with the purpose of identifying who is responsible for what cleaning and checking and allocating and monitoring those tasks accordingly. There is a centralized housekeeping department in hospitals which only does major cleaning. In the 5S approach, the light cleaning and overall cleanliness of the department could be done by people who work there through a team s daily or weekly Standardised work routine. 658

8.2.4 Standardise The establishment of workplace procedures or fourth S tends to maintenance of standards. It is important to define a best location for the needed items and then ensure that they always kept in the defined position. It results in number of benefits to employees or physicians who work in multiple units in hospital. Standardise often happens through visual methods such as the marking of home locations with vinyl tape or shadow outlines. Marking of home locations with vinyl tape have benefit of ability to see instantly which item is out of place or missing, reduce the wasted time searching for items and return items to their locations easily. Shadowing happens by a physical outline or photo of an item that should be in a location. 8.2.5 Sustain The fifth and the last s, is about sustaining and continually improving of organizations, adding up to identification and assignment of responsibilities to people as a regime for review is being established. Through a scheduled basis, the supervisors of a hospital are able to check that a standardised work audit is following new standards. 9. Flow Moving from batch and queue towards flow through a value stream should be a one of the main hospital s goal. In the hospital environment smooth flow is necessary for both patient and products. The flow can be improved through reducing and eliminating waiting, interruptions, and delays from the value stream instead of doing the value-adding work faster. First of all, the problem that causes these delays should be identified. As an example, in a surgery department, the source of delay might be: Patients sometimes show up late, lab results are not always back in time for the surgery, supplies or tools needed to start surgery are missing, and surgery lengths are unpredictable. Finding their reasons could solve some of these problems. Such as patients delay which might be due to lack of clear signage and a confusing hospital layout. 659

9.1 Improving patient flow One of the most important issues in hospital is the problem with patient flow. This could be solved through using the concept and method of Lean in order to identify blockages and obstacles that cause delay, and remove them. In many support functions in hospitals where the primary product for a continued care is an item rather than patient such as laboratories, pharmacies, perioperative services, and nutritional services, Lean methods have been used in order to improve the patients flow. 9.2 Improving flow in clinical laboratories The Lean methods have been widely implemented in different parts of clinical laboratories in hospitals such as the clinical lab, transfusion services, microbiology, and anatomic pathology. During multiple stages of testing in a clinical lab such as specimen collection, receiving, or testing areas, that are basically the value stream the specimens may be delayed. As the clinical labs are usually experiencing large number of testing and critical turnaround time expectations, the Lean method can play a significant role. 9.3 Improving Patient Flow in the Emergency Department The congestion time in EDs impacts both patients and employees. In one hand, the patients start to complain about the delays, especially the delays between different steps in the value stream, before being admitted or being able to release. On the other hand, as the number of patients complains increases the ED employees feel unable to fix the system. They may even be blamed by newspaper s headlines for complains, while one may find the root of the problem in other part of the value stream. As the ED hallways are not private room to wait they may therefore become an overcrowded and mentally stressful place. The Lean methods can be used to improve the processes in an emergency department such as patient flow. As the patient flow, by improving the processes hospitals can eliminate the waiting times. 10. Conclusion In order to minimise waste for patients and for employees in hospital a Lean hospital is physically designed. Rather than forcing departments and employees to adjust their activity to the limited space, 660

its design supports workflows and value streams. A Lean hospital has process technology, automation, and information systems that make work easier or better error prevention. At one hand, Lean can improve safety and quality, on the other hand, improve staff morale and reduce costs. The Lean message is 100 per cent positive; through releasing human potential it can add value to patient care and consequently improve quality. It can create a virtuous circle rather than perpetuating vicious ones. But Lean needs leadership and leaders and won t just happen on its own. It requires people who really demand the change and also able investigate how to do it collectively and win senior management support. It requires managers with the vision to give staff chance to experiment. References DOH(2001) Press Release 16 November 2001 http://www.dh.gov.uk/en/publicationsandstatistics/pressreleases/dh_4011531 Graban, Mark.(2009) Lean Hospital, Productivity Press, New York Daniel Jones and Alan Mitchell, (2006), Lean thinking for the NHS, Lean Enterprise Academy UK. Available at: http://www.nhsconfed.org/publications/pages/leanthinking.aspx Davies, Tom, Fatal Drug Mix-up Exposes Hospital Flaws, Washington Post, September 22, 2006, http://www.washingtonpost.com/wp-dyn/content/article/ 2006/09/22/AR2006092200815.html?nav=hcmodule (accessed May 10, 2009). David Ben-Tovim (2006), Can Lean Save Healthcare? available at: www.leanuk.org/downloads/health/can_lean_save_healthcare.pdf - Galsworth, Gwendolyn,(2005), Visual Workplace, Visual Thinking, Visual-Lean Enterprise Press, Portland. Hart C (1998) Doing a literature review, London, Sage Liker, Jeffrey K.,( 2004),The Toyota Way: 14 Management Principles from the World s Greatest Automaker, McGraw-Hill, New York NHS(2008a) 18 week target initiative http://www.18weeks.nhs.uk/content.aspx?path=/ accessed 4th May 2009. Productivity Press Development Team,( 1996), 5S for Operators Productivity Press, New York. Ridley, D. (2008), Literature Review: A step by Step guide for Students, SAGE Publications Ltd, London 661

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