The Lean methodology is a set of practices, tools, and principles that business leaders initially developed to help manufacturing organizations improve quality and become more efficient. The approach was built on concepts included in the Toyota Production System, which helped Toyota gain a stellar reputation for quality and affordability.
The benefits of Lean management are not confined to manufacturing. The ideas and tools broadly apply to any organization that wants to maximize customer value while enhancing profitability for the long term. The Lean approach to process improvement is leveraged in areas as diverse as software development, construction, education, and professional services. For many reasons, Lean has been particularly embraced by healthcare organizations over the past 20 years or more. The details of how Lean is practiced in healthcare vary from its use in manufacturing, but the core concepts of value creation, continuous improvement, and respect for people are the same.
The Six Principles of Lean in Healthcare
John Toussaint, MD, and former healthcare CEO, and Leonard L. Berry, professor of marketing at the Mays Business School of Texas A&M University, developed a set of six principles of Lean in Healthcare and published them in the Mayo Clinic Proceedings. They are as follows;
Lean is an Attitude of Continuous Improvement
Lean leaders recognize that perfection is impossible, yet they create the conditions and the mindset to push toward it through a series of constant process improvements. Lean isn't a project or a series of projects; it is a way of thinking about problems and constantly experimenting with solutions in a scientific way. The Lean methodology in healthcare requires active management and measurement.
Lean is Value-Creating
The goal of Lean in healthcare is to create better value for the patient. Doing so requires aligning with the patient's health goals, minimizing non-value-adding activities, and measuring improvement through the eyes of the patient.
Lean is the Unity of Purpose
Lean leaders share and socialize the long and short-term goals of the organization. They ensure that these goals have meaning beyond financial measures, allowing everyone in the organization to form an emotional connection to the organization's purpose and their own individual purpose. This unity improves decision-making, reduces conflict, and fosters employee engagement.
Lean is Respect for the People Who Do the Work
Lean leaders recognize that the people who are closest to the patient are the ones in the best position to identify and implement the most opportunities for improvement. Leaders show respect when they listen to and act on ideas from every member of the organization, including support staff, administrators, and clinicians. The leaders' actions might include coaching and facilitating the frontline staff to work on improvements, or they'll serve as servant leaders to address more systemic issues than the frontline staff and their local leaders can address alone. Every employee has the potential to contribute to positive change. Lean in healthcare, as would be true everywhere, has the idea of "every person, everywhere, every day" improvement.
Lean is Visual
One aspect of "visual management" is how we visualize our performance measures. While data visualization may seem like more of a tool than a principle, it is fundamental to the Lean methodology. Lean organizations use visual cues for everything from strategic planning to inventory management. For example, in healthcare, popular Lean visual management techniques include digital huddle boards, value stream maps, control charts, and kaizen dashboards. These visual management, going beyond simple metrics, help us see the difference between normal and abnormal conditions at a glance, so we can take prompt action.
Waste Reduction in Healthcare
Creating maximum value for patients means improving processes in a way that eliminates activities that are unnecessary to either fulfill the needs of the patient, comply with regulations, or enable ongoing value-added work in our operations. As in manufacturing, Lean leaders in health systems look at and describe several common types of waste to find opportunities for improvement.
Defects are a problem in manufacturing, but they can have catastrophic consequences in healthcare. Examples of defects in healthcare include misdiagnosis, surgical errors, avoidable hospital readmissions, preventable hospital-acquired infections, billing errors, medication mistakes, and incomplete medical records.
Certain supplies are essential in a healthcare setting, but purchasing supplies that aren't needed in the short term leads to storage problems, potential spoilage, and capital that is unavailable for other uses. Excess inventory in healthcare includes unused equipment, pre-printed forms, medical supplies, and medications. Lean organizations do as much as possible to create a just-in-time approach to inventory management, making sure we have the right things, in the right place, at the right time. Our first goal is to prevent interruptions to our work, while the second goal is to do so without excessive inventory.
The waste of waiting is perhaps the most visible of all the types of waste in healthcare. Some waiting can't be avoided, of course, but leading organizations look to reduce it as much as possible. Waiting includes time that patients spend waiting, and lean healthcare organizations work to significantly reduce waiting times instead of assuming that it always has to be that way. We also look to reduce the time spent waiting by staff members and providers, with one of the causes of waiting being, again, a lack of inventory or supplies.
Transportation waste happens whenever equipment, supplies, or people are moved unnecessarily. For example, a patient might be moved from his hospital room to radiology for an x-ray, back to his room, and then back to radiology for an ultrasound. Unnecessary transportation increases the risk of damage to equipment or injury to patients. It is often the cause of the waste of waiting. How can we minimize transportation by improving the design of our system, such as changing the physical layout of the space or bringing portable diagnostic equipment to the patient?
Similar to transportation, the waste of motion occurs when employees perform movements that do not add value to patients. In many cases, the waste of motion is the result of poorly designed or inadequately stocked workspaces. For example, if a healthcare provider needs to leave the exam room to get something they need, a waste of motion has happened. These are systemic problems and require systemic improvements -- as with other forms of waste, we aren't blaming individuals for being wasteful.
In manufacturing, overproduction means that more of a product is created than the customer needs at the time -- making too much and/or making it too soon. In healthcare, overproduction includes ordering medications or meals for patients who no longer need them, unnecessarily extended hospital stays, and creating forms or documents that the patient doesn't need or want. Ordering too early and/or ordering huge batches because we think it's "efficient" could lead to much more waste as a result.
Over-processing takes place when effort is expended that is unrelated to the patient's need or outcome. For example, unnecessary diagnostic tests are a common form of over-processing in healthcare. Other examples include multiple documents with the same data, duplicate data entry, and unnecessary referrals to specialists.
Un-Tapped Human Potential
The Lean principle of respect for people goes hand in hand with the idea that when employees are not invited to participate in continuous improvement, human potential is wasted. Moreover, without tapping into every employee's perspectives, ideas, knowledge, and insights, an organization is unlikely to succeed at reducing all of the other forms of waste. In a positive example, our customer UMass Memorial Health has implemented (and documented) over 100,000 employee ideas in recent years!
Tiered Daily Huddles
One Lean technique that has been particularly effective in large healthcare systems, including the Cleveland Clinic with more than 66,000 caregivers, is tiered daily huddles. These meetings are a series of short, focused conversations that happen daily across the hospital system. The goal is to create an open flow of communication from the front-line staff all the way to executive management -- both up and down the organization and laterally across areas. When a team member reports a critical issue, it is escalated to the senior management team within hours to get help and/or to spread the knowledge and learning that's occuring.
Every organization takes its own approach, but most have a similar structure:
Tier 1: Caregivers & managers/supervisors
Tier 2: Managers & directors
Tier 3: Directors & hospital leaders
Tier 4: Hospital leadership
Tier 5: Hospital & enterprise clinical leaders
Tier 6: CEO & Operations Council
This approach ensures that by mid-day, any problem that managers can't solve at the point of care receives due attention and that someone is made accountable for each issue. Even if a problem has been solved, the problem and solution are communicated upward so learning can be spread.
The Centers for Medicare and Medicaid Services predict that national health spending will grow at an average rate of 5.5 percent per year, reaching $5.7 trillion by 2026. To sustain that rate of growth, much change and improvement is needed. If our already-overtaxed system is going to avoid collapsing under its own weight, a focus on customer value is required.
By the way, the problems described here are pretty universal and are not just a United States problem.
Many health systems have begun this transition to a more customer-centric framework. That's why Lean is so valuable. By focusing on the core question, "Does this provide value for the patient?," organizations can reduce waste and improve employee and customer satisfaction while maintaining profitability.
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