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 system, Lean 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.