From the factory floor to the emergency department: Hospitals explore Lean method

Can health care learn from assembly lines?

Manitoba’s St. Boniface General Hospital thinks so. It’s been using Lean, a system inspired by Toyota, on processes around the institution. Last year, one of its projects was to reduce wait times for CT scans. Staff ran a Rapid Improvement Event, where a team mapped out patient flow and looked for possible improvements. And they found them. After cutting out repetitive forms, removing unnecessary steps and creating a single patient registration spot, wait times dropped from an average of 26 minutes per patient to eight minutes.

The hospital began working with Lean in 2007, and has since gained a reputation for being one of the strongest supporters of the process. But it’s far from the only one, as Lean is being implemented in health care institutions across the country. Proponents believe the efficiency-focused philosophy reduces waste and offers a solution to our increasingly burdened health care system.

However, critics argue lessons from a Japanese manufacturing system aren’t transferable to health care and that Lean’s benefits remain unproven. Saskatchewan instituted one of the largest tests when it began implementing Lean in health care institutions across the province. Four years in, it’s revising its plan in the face of mixed reviews.

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The Lean system

Modelled after Toyota’s production systemLean is focused on rooting out waste. It’s what allowed Toyota to provide low-cost cars, as well as the variety customers wanted, giving it an advantage over slower-moving competitors like Ford. The system’s core concepts reflect those lessons, targeting efficiency and the desires of the customer. (In the health care system, the customer is translated to mean the needs of the patient.)

Before reaching health care, Lean spread to other manufacturers, the service industry and airlines. “Fifteen years ago people had sort of a hypothesis that Lean principles could apply in health care,” says Mark Graban, consultant and author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. Early innovators in Seattle, like the Virginia Mason Medical Center, began using Lean and saw results. It has since been used in health care systems across North America, in the U.K. and in Australia, including hospitals and Family Health Teams.

Groups are often sent to Toyota plants in Japan to see how Lean works firsthand. But most don’t go to hospitals. “Ironically it’s probably not used as much in Japan as it is in the United States,” says Graban. “There are cases where you have Japanese hospitals flying to Seattle to learn about what they’ve learned from the Japanese.”

A typical Lean scene includes a group of all levels of workers, from physicians and managers to administrative assistants and cleaning staff. They write out the path patients take to get to a target, like seeing a doctor in an emergency room, and look for waste that could be cut out of that flow. Common areas include overproduction, such as making unnecessary copies of reports; wasting time, from things like long wait times for test results; or wasting movement, such as having frequently used supplies in other rooms. The process doesn’t end when the meeting does – institutions are supposed to strive for continual improvements.

“It’s a valuable methodology for the vast majority of organizations,” says Brian Golden, chair in Health Sector Strategy at the University of Toronto and the University Health Network. “They’re asking their staff to start with a fresh slate, a whiteboard, and think about everything that needs to get done that’s valuable from a patient perspective.” Ideally, it results in more patient-centred care, lower wait times and fewer errors, while saving money.

Ward Flemons, Health Quality Council of Alberta medical advisor, helped test Lean for the Calgary Health Region. “We ran about six or eight different Lean projects facilitated by Lean improvement specialists, and by and large the people who were in the improvement projects spoke very highly of their experience.”

One he worked on involved decreasing emergency room wait times. After tracking how much time physicians spent travelling between patients, the team found doctors were spending as much time walking back and forth as they were treating patients. So they flipped the system and had the patients come to the doctors, by creating zones for different conditions. It decreased the amount of time doctors spent travelling back and forth from 51% to 4%, and wait times dropped by 21%.

Saskatchewan’s Lean initiative

After a province-wide Lean roll-out in health care, Saskatchewan recently announced it was reducing its contract with its Lean consultants. The four-year, $40-million contract with John Black and Associates, a U.S. Lean consultancy company, will be shortened by about nine months, says Dan Florizone, deputy education minister and deputy minister responsible for Lean. “We have a need to become more self-sufficient in our Lean deployment,” he says. “It’s really about weaning ourselves off consultants.”

Florizone brought Lean to the Five Hills Health Region in 2006, when he was CEO, which included sending staff to learn from Seattle’s Virginia Mason. By 2010, he was health minister and implementing Lean across the province. Three aspects of it resonated with the government, he says: the focus on the patient, the goal of having zero safety defects, and the importance of engaging front-line providers.

The program to date has included giving almost 20,000 Saskatchewan health care workers a one-day overview of the system and flying in Lean senseis (coaches) from Japan. It has also faced criticism. “Now that Lean is being put into practice, we are seeing the primary focus is on creating efficiencies, waste reduction and budgetary savings only,” the Saskatchewan Union of Nurses said in a statement.

The union is also unhappy about administrators following nurses with stopwatches as part of Lean. And others have also complained about the sessions. Deputy minister of health Max Hendricks told The StarPhoenix, “They’ve said, ‘We learned Japanese terms. We look at videos about the Toyota loom. We fold paper airplanes.”

“I don’t have a big problem with building [paper] airplanes … we’re trying to get health care folks to think outside of the box,” says Florizone, who adds that stopwatches may be helpful if they’re used appropriately. But concerns are taken seriously, he says. One of the complaints was about the Japanese terms, and as result, they’ve tried to use more plain English when possible.

A Canada-wide trend

Dozens of hospitals in Ontario have also used Lean, including Toronto’s University Health Network, North York General Hospital and Windsor’s Hotel-Dieu Grace. One of the most notable successes was using Lean to reduce wait times in the emergency department. At Hôtel-Dieu Grace, Lean helped significantly reduce emergency wait times, decreasing average length of stay from 3.6 hours to 2.8 hours, while increasing patient satisfaction. But a recent study found that Lean may not have deserved the credit. “Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance,” it concludes.

Other provinces have also implemented it, including Quebec and British Columbia, which used Lean in more than 35 health care facilities across the province in 2011/12. Alberta used Lean to create its own strategy, which incorporates principles from Lean and Six Sigma, a similar technique developed by Motorola and popularized by General Electric often used alongside Lean. “We didn’t want to use the brand or say Lean because people have preconceived notions that we are imposing an outside model onto them,” says Anurag Pandey, executive director of Process Improvement at Alberta Health Services. “We just took out some of the jargon and combined it into something that health care professionals can more easily understand.”

One Alberta initiative targeted access to radiation therapy across the province. It began with oncologists, nurses and managers looking at how patients went through the system. They began simple improvements, like processing faxed requests as soon as they came in, rather than letting them to pile up. The clerk and triage nurse sat together to process the information, and they also centralized scheduling. In the end, wait times to see an oncologist dropped from seven weeks to less than three.

Though Lean offers plenty of these success stories, most of the proof remains anecdotal. A 2010 review in the BMJ Quality & Safety journal found 33 articles on Lean that all had positive results, though most were “narrower technical applications with limited organizational reach.” The same year, a review in Quality Management in Health Care found that the approach seems to have been “adapted rather than adopted.” It points out that many organizations often seem to skimp on the final two steps of lean: establishing pull – providing product as needed, in smaller batches – and seeking perfection. Though all the articles it found were positive, “Many articles found in the area have a speculative character and are not based on empirical evidence,” it concludes. “More rigorous and holistic research is required to evaluate the real impact and to understand more about underlying factors influencing the success and sustainability of Lean in healthcare.”

Concerns about cutbacks

Some healthcare workers, disliking the idea of comparing hospitals to factories and worried that Lean will lead to job cuts, haven’t taken to Lean. “In health care there’s always a hesitancy towards adopting methodologies that are from non-health care industries, because people are naturally suspicious about how is this actually going to work,” says Flemons. “I’ve been in forums where I’ve heard CEOs basically say they wouldn’t go near it because of the connotations that it has.”

Another challenge is that the term Lean evokes images of cutbacks. “Lean for a lot of people implies cutting out the fat, and there aren’t a whole lot of people who like thinking of themselves as fat,” says Golden. Some organizations have pledged the process won’t lead to job cuts to try and ease these fears. Others worry Lean is a fad, following on the heels of management techniques like Total Quality Management. Adding internal staff to the Lean leadership team can help counter wait-them-out attitudes. “Ultimately these organizations need to internalize these capabilities,” says Golden. “[Lean consultants] need to teach the organization how to fish.”

No matter what the system, changing the culture of organizations is difficult. “Generally if you look at the success rate or sustainability of improvement work, it’s not that good,” says the AHS’s Pandey. “Even in our own projects, [working to improve] the emergency departments, we had really good successes in two of them, and three others that we worked on that were not so successful. It is a tough game.”

Michael Carter, director of the Centre for Research in Healthcare Engineering at the University of Toronto, thinks Lean works – some of the time. “Lean takes you so far and then you hit a wall,” he says. “In some respects, it’s about low-hanging fruit.”

But it does work well for helping health care organizations see where they can make improvements such as saving time, documenting better, and communicating patient results more clearly. And it’s changing how health care workers think. “Twenty-five years ago I would talk to people about patient flow or standard work, and nobody knew what I was talking about. Today, [it seems like] there’s nobody who hasn’t seen a flowchart and gone to brainstorming sessions,” he says.

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  1. Michael Schull

    Ontario’s MOHLTC launched a major Lean initiative targeting ER waiting times in 2009, and we recently published what we believe to be the largest controlled study to date of Lean. It is available freely here:

    We compared outcomes (both wait times and other quality of care measures) in 36 hospitals that underwent Lean with 63 matched control sites that did not undergo the MOHLTC Lean program. We found that while waiting times did improve in Lean sites, they improved just as much in control sites. We found no evidence of effects (positive or negative) on other measures of quality of care associated with Lean when compared with control sites.

    It’s important to note that ,in Ontario, Lean was launched as part of a broad MOHLTC strategy, which included standard ER wait time targets, public reporting, and financial incentives that affected all ERs. Overall, ER wait times have been dropping in Ontario and target performance improving, but those ERs that underwent Lean do not appear to have improved significantly more than sites that did not undergo Lean, in a context where all hospitals were exposed to other aspects of the ER strategy. An incremental benefit of Lean when added these other policy measures was difficult to discern.

    My take-away is that %featured%wide-scale efforts to implement Lean is a costly and unproven approach to improve performance in health care. Targeted local efforts in performance improvement, based on Lean or other similar approaches, can likely still be beneficial%featured%.

    • Ron Wray

      Interesting findings yet not surprising.

      Just as there are stock market ‘bubbles’ or real estate ‘bubbles’, there are public policy ‘bubbles’. Concentrated bandwagon activity around a particular policy or operational idea that is supported by outsized claims of positive outcome (typically by an active cadre of consultants), but weak evidence. In the end, the ‘bubble’ bursts as evidence begins to suggest the costs do not necessarily out-weigh the benefits that are too often marginal or negligible. Then policy ‘investment’ moves into the next idea.

      As more and more, health policy is driven by a business school mentality expect to see an increasing frequency of ‘bubbles’ at an ever higher cost of failure.

      One can add Lean to the long list of such ‘bubbles’ in health care.

      • Dr. A

        I am a pathologist.

        Our field has been Leaned to death. I’m tired of it.

        Nobody has actually asked people who are under some sort of Lean-based program how they feel about their work. In my experience it removes autonomy and turns one into a cog worker. Not very good for morale. Many share my sentiments, but I cannot back it up with factual claims.

        Lean, from my readings, seems to have more effectiveness in capitalist market-driven systems like corporations. %featured%In cost-containment systems like health care, where the final product, patient care, is not valued against others providing the same service, Lean has little effect but to add to the list of ever-so-annoying initiatives thrust upon those within the system.%featured%

        • Mark Graban

          If there are so-called “Lean” methods being used in your workplace, Dr. A. and “nobody asks how you feel about your work,” that’s not really Lean. Toyota engages their employees in the improvement of their work and that is the ideal that Lean should represent.

        • Alice

          I am in agreement. You feel like a robot and all your creativity and training is being taken out of you

  2. Hugh West

    I found this article very interesting and helpful. Being on the board of a ccac, I wonder how we can apply principles of Lean. %featured%To focus on the implications of the word LEAN or on the fact it’s origin is from the auto industry is senseless. Better to focus on what can be gained or how Lean can benefit an organization is profitable. %featured% After all, board responsibility is fiduciary, efficiency, while at the time adhering to the vision, mission and core values of the organization.

  3. Mark Graban

    Thanks for including me in the piece. There are a few minor problems with the upfront definition of Lean.

    1) Reducing waste is a big part of Lean, but the primary goal is “providing the most value” to the patient (the right care, the right time, the right place)… doing so with as little waste as possible.

    2) %featured%Lean is not about “efficiency” or a drive to have everybody be busy. The main pillars of the Toyota Production System are flow and quality.%featured% The primary focus is on, for example, patient flow. Sometimes the best patient flow comes from having slightly lower efficiency (if efficiency is calculated as outputs divided by inputs). Efficiency might be an end result of better flow and better quality, but efficiency is not the primary goal.

    You can read good definitions of Lean here:



  4. Leslie Ayre-Jaschke

    I don’t know if it’s an explicit part of Lean itself, but I very much like the idea of “customer-in thinking” vs “product out” that is part of the Japanese perspective and systems thinking (and described very well in a gem of a book from 1998 called The Leader’s Handbook by Peter R. Scholtes).

    Part of this thinking is finding ways to give the customer “delight” (like reducing wait times for external customers or saving staff valuable steps, for internal customers). How motivating this could be, and is a way of keeping the customer front and centre as solutions to problems or challenges are found.

    If Lean processes keep the patient/consumer/customer experience at the forefront, perhaps some of the concerns about it being too mechanistic or just a way to cut waste would be alleviated. %featured%How much patients/citizen involvement occurs as part of the process? We’re rather an important part of the system, so involving us where feasible seems essential.%featured%

    • Mark Graban

      Many healthcare organizations practicing Lean are very directly involving and engaging patients in the improvement and redesign process. They are talking to their patients (instead of the hospital assuming they know what patients want and value) and patients are part of the improvement teams for “rapid improvement events” and other improvement work.

    • Nevoohpred

      Yes, a fad that has has been here for almost a century.

  5. Robert Pental

    I am going to pipe in from the other side of the debate as one of those who is hesitant about the Lean process. Now before you dismiss my declaration as non-committed or overly suspicious, I would like you to hear me out, because in practice, being efficient, thorough, practical, and reflective are the key gears in the operations of a productive and evolving system.

    Where then do I differ in opinion and why does it place me into the hesitancy camp? It begins with the product, or in less fanciful language, with an appreciation for the raw material we bring into and engage in the Lean process. A process that by definition is meant to strip away, however diplomatically, inefficiencies, defects, and variations which remove value from the end product. Moreover, and I do not imply we lose sight of the important end product, rather, to better increase the performance of the system itself, and what we suppose the end product to be, we need to appreciate what is coming into a Lean/Sigma system. Furthermore, how the pre-production material does not equate with innate manufacturing and thus why I am hesitant.

    For example, when a product or raw material is brought into be otherwise redistributed or engineered or facilitated that raw material is in fact an end product of a previous system. To put it another way, for the Lean purposes of removing errors and statistically being able to monitor them, the initial material in an innate manufacturing process begins with a measurable amount of errors removed.

    In healthcare the exact opposite is the case. In healthcare the client coming into a Lean process, as it is defined, has not had variations or errors removed in order to begin a next stage of development but is instead antithetical to what the Lean process proposes to do. For instance, a client upon their entrance to healthcare, while having reached a peak in performance, that peak is the cumulative effects of what amounts to their vulnerabilities and not efficiencies . Although, some may say the contrary and clients are merely performing to their entropic best, I optimistically put forth there remains within us the capability to redirect the flow of energy.

    What do we do? First, we need to see Lean processing is not, as some would argue, where it all begins, but is part of a larger process of transformation. Second, bearing in thought the first point, to see that Lean management produces a final product that truly enables the transformation of health care from a vulnerability enabling method to self empowering system of renewal, we need education to be as efficient and as lean.

    In other words, we need to develop a way of looking at what it is that makes us vulnerable in the first place and reduce, wherever possible, the means by which these contribute to disadvantage our individual and collective well being. Call them social determinants of health or factors of societal well being makes no difference to me. Moreover, it will only be when we addressed these precursors to our health will a Lean system of error monitoring be an effective partner to healthcare.

    Until such time, what is offered makes me hesitant to believe any real concrete and measurable changes to will come about except for those who live to profit off the misery of others.

    • Dave S

      I agree that we need to better address root causes of health care use and costs. However I believe you have made a category error in your analogy. The client is not “raw material”, the client is in fact the customer. The customer always has varied requirements and expectations. In manufacturing the customer requirement is a new product/design that may require new processes and materials. In health care the the requirement may be a special medicine/treatment or expert. The flexibility to handle this type of situation is the strength of lean. I would agree with you if we were talking about a mass production system but lean is in many ways antithetical to mass production.

  6. DJS

    Adapting corporate practices to universal healthcare? Why not take a page from Nike and just move all health services offshore? Now that’s lean.

    • Mark Graban

      Nike is not a “Lean” company and there’s nothing inherently Lean about offshoring. Note how Toyota builds products close to their customers, including in Ontario and in the U.S.

      Even General Electric saw the light and moved much of their appliance manufacturing back to the U.S. (in Kentucky) because the Lean thing to do is to be close to your customers. Traditional companies chase cheap labor. Lean is an alternative.

    • Mark Graban

      Lean has nothing to do with outsourcing and offshoring. Toyota builds plants close to their customers (as in Ontario and across the U.S.).

      Even GE, which fell in love with offshoring, has brought appliance manufacturing back to the U.S. (Kentucky) because the total costs are lower. GE used to look primarily at labor cost, it seems. The Lean approach is to be close to your customers.

  7. Ann-Marie Urban, RN, RPN, Assistant Professor, Faculty of Nursing, University of Regina, SK

    While I believe that there are merits to reducing waste and improving efficiencies in hospitals, it is also important to recognize that every patient has unique care needs which do not fit with production line caring. For example, the increasing number of bariatric, mental health, dementia and palliative patients requires nurses to have specific skills and knowledge when delivering their care. As such, the increasing physical and mental demands of the work have resulted in high absenteeism and disability rates. Back problems, pain, anxiety and depression continue to be problematic amongst nurses. Nurses strive to put their patients first however because of ongoing hospital problems, they are frequently placed in situations where they lack the time, and the resources to care for patients in the way they would like too. More importantly, nurses’ ill health jeopardizes the provision of safe, quality patient care. While lean methods of improving efficiency and cost cutting strategies are important for hospitals, they often ignore the health of nurses. Strategies must look beyond serving only the needs of the hospital and governments; they must also support nurses to provide safe, quality patient care. Nurses’ well-being is important since, if they cannot work or if patient care is affected by their ill health, patients and ultimately all of us will be affected.

    Ann-Marie Urban, RN, RPN, Assistant Professor, Faculty of Nursing, University of Regina, SK

  8. Andrew Holt

    Is our challenge one of selectively adopting some of the principles, methods and tools developed for LEAN while realizing their limitations when applied to the complex human dynamics associated with health care versus producing a car? Could LEAN be more applicable in some areas of a hospital – purchasing, materials management, facilities management, finance, nutrition services, lab, DI, pharmacy, ORs … but less so in others? Is a more targeted use of LEAN more appropriate to healthcare? It would be interesting to have a comparison study to learn from experiences in healthcare.

  9. JK

    Despite rhetoric to the contrary, Lean in healthcare seems to be principally about seeking to make cost efficiencies and get ‘more for less’ where the inevitable end point is ‘less for less’. I have serious concerns for patients in such a system which disguises the true nature of this enterprise in the reassuring but often misleading language of both ‘improvement’ and ‘quality’.
    The National Health Service of the UK has in recent times been found wanting with regard to care quality (See the Francis Report) with the finding that in some places corporate and organizational reputation needs eclipsed the very basic needs of patients. Lean perpetuates this risk in often reducing staff levels to a bare minimum, demoting staff through reorganization after reorganization, maximizing and prioritizing bureaucractic activities, and implementing a ‘hard’ HR. 5S activities are one thing, but Lean per se is not without risk in the hands of bureaucrats in times of austerity. See also ‘The Effect of Lean Systems on Person-centred Care’.

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