Lean healthcare in the world

It was noted that the Lean Healthcare is not only a production system but also a system that refers to other departments of the company, including the management. In the 21st century, many lean management solutions have been used in hospitals  to carry out activities related to health care and adapting the methodology to the specificity of health services – lean hospitals have emerged, especially in England and the United States. In Poland, it is still a field of undiscovered possibilities. Polish hospitals benefit from technical innovations directly related to medical equipment but not from innovations in the organization and management system. This is a great opportunity for most public hospitals that have credit obligations,, lack staff or materials for efficient functioning.

“Lean Healthcare system is a set of tools, management, and philosophy that can change the way hospitals are organized and managed. The Lean Healthcare is a method that allows hospitals to improve the quality of patient care by reducing the number of errors and reducing waiting times. The Lean system is a concept that can support doctors and other workers, eliminating their difficulties and enabling them to focus on those activities that serve to cure and care. This system helps to improve  the organization of the hospital for a long time – by reducing costs and risks while increasing opportunities for growth and development. Lean hospitals help break the barriers between separated hospitals wards, which allow them to work better together for the benefit of the patients.” [Graban 2011].

The objective of lean hospitals is not a one-off solution to a single problem but a counteraction to many of them. Health care costs are rising faster than inflation that means spending exceeds available resources. Due to the rising costs of maintaining medical institutions and their employees, all forms of “improvement” are sought when the payer also has less money (In Poland it is The National Health Fund) and limits the amount of refunds by reducing own expenses and  creates problems for providers. Real costs of services in most cases exceed their refund, which makes medical institutions loss millions of Polish złoty and their managements are forced to implement cost-effective cost-cutting methods – lean hospitals can effectively support them.

According to The Institute of Medicine, there are 400,000 injuries each year in US medical institutions that are caused by improperly administered medicine [NHS 2012]. In hospitals there is a possibility of elimination of processes that don’t affect the effectiveness of patient care. Sometimes it is a change of procedures, habits and sometimes putting the patient to another type of treatment, which means cheaper and less painful therapy. Medical institutions would work better if the results of treatment had an impact on the level and quality of contracts with the payer.

Below are presented some examples of hospitals in the world, that saved time and money by using lean hospitals methods:

1. Avera McKennan Hospital in South Dakota shortened the hospitalization of patients by 29%, which allowed them to avoid a $ 1.25 million investment in a new emergency department building.
2. At Allegheny Hospital in Pennsylvania, mortality was reduced by 95%, due to blood infection associated with central venous catheter.
3. The ThedaCare Hospital in Wisconsin has implemented improvements to reduce patient waiting time for orthopedic treatments which shortened the waiting time from 14 weeks to 31 hours (from first visit after treatment).

Maintaining a good quality of service greatly reduces costs. One of the hospital’s financial directors in the US, Bill Douglas summarized the activities of lean hospitals as follow: “If your actions are focused on quality and patient safety, then you can’t lose”[Graban, 2011]. Each medical intuition has the possibility to reduce the cost of its activities, not necessarily with dismissal of employees or purchases of new devices, there are other solutions, but the lack of awareness of the management of medical institutions in this direction and lack of desire makes the institution struggling with problems that are difficult to solve. Lean hospitals can be a basic strategy for an entire medical institution by creating daily activities, both in self-employment and in the continuous monitoring of activities performed by employees.

Lean hospitals are a well-developed system in hospitals in England. Based on the publications of the NHS-Institute for Innovation and Improvement, the following lean management improvements will be discussed below.

• Poole NHS Trust Hospital in the UK in 2009 introduced many changes in the organization of work. To keep the documents intact, separate cabinets of different colors have been installed, blue for doctors and red for nurses. Reduced medicine delivery time to patients by average 100 minutes each morning by work of two nurses: This was possible thanks to the division of duties of two nurses. One nurse gave medicine to the patient and the other one was dealing with the patient’s medical records at that time. Patient identification was also introduced by the numbering the beds from 1 to 30 and their location, by placing additional information on the patient’s board (for example x-ray room). In order to save space, hospital wards have updated the state of bedding and returned 153 unnecessary pillows to laundry [NHS Case study 1].
• In the children Birmingham Children’s Hospital NHS Foundation Trust the process of patient information has been improved by issuing a booklet that informed about patient’s stay in the hospital ward and also included the most frequently asked questions by interview with young patients. This has helped to improve the comfort of the families of children in the hospital ward and reduced the time spent discussing the concerns with the doctors. There were a lot of mistakes in the medicine distribution process, so there was decision to visualize  the medication carts for patients by labeling them in red. This resulted in that no one was bothering the nurses unless it was an urgent call. This has led to a decrease in the number of medicine distribution mistakes, improved patient safety, and increased patients trust due to the ability to talk without interruption [ NHS Case study 2].
• In Leicestershire Partnership NHS Trust hospital the visual condition of the institute was improved, the paintings were placed on the walls, so that the interiors became more cozy and warm. The waiting time for surgery was also reduced by 120 min [NHS Case study 3].

Examples of similar improvements in US hospitals:

• The Wisconsin’s Monroe Clinic hospital in US saved a lot of time by focusing on important and significant processes. The payment system for private medical services has been improved, so the hospital is paid after 6.5 hours and not after 12 hours.

The solution has enabled a possibility to disposal of greater cash which increased opportunities for service development and equipment purchases. Adopting a patient to the emergency ward now takes 10 minutes, and before the introduction of VSM, it took 3 hours to get there. It also reduced the process of reception and discharging the patient from the hospital from 125 minutes to 70 minutes by reducing the number of documents filled; Patient and hospital staff satisfaction has increased. It is a comfortable solution for the patient because he is less stressed by standing in queues, waiting, walking from the office to the office and also in the hospital there are no queues and unnecessary crowding [HPP Case study 1].

• In the Florida Hospital the main tool was mapping of value stream that improved the process, increasing patient satisfaction of nursing care by 86% compared to the previous year, increase in the satisfaction of hospital staff from work performed, reduction of time for daily activities (7000h per patient per year) and also it caused the reduction of calls to nurses by patients at night by 1700h per year [HPP Case study 2].
• In Oklahoma City Hospital focused on communication between the patient’s family and the hospital staff. By using boards and IT solutions which track a patient’s stay in hospital, the number of questions about patient place of residence reduced from 75 to 0 per day.
• The number of central venous catheter infections has also been reduced by implementing standardized procedures, VSM, purchase of better puncture packs and better communication among nurses [HPP Case Study 3].
• In Middle Tennesse Hospital nurses pathways were improved using a spaghetti diagram. It was found that the nurse needed 81 minutes to give the medicine to 3 patients. Only 26 minutes of that time was spent directly with the patient. Important time constituted only 31%, the rest was walking, logging into the system, looking for medicine. The medicine delivery time by nurses was also reduced from 45 min to 4 min per 1 nurse on working shift, by increasing the time spent with the patient by the nurse [HPP Case Study 4].

By Analyzing medical institutions, it is worth to observe the needs of Polish patients and on this basis perform improvements:

• Improve the organization of the reception room by shortening the time of formal activities.
• Improve communication with patients, systematically distribute patient leaflets with Patients’ rights
• Improve sanitary-hygienic conditions by adapting the bathrooms to the patients
• More precisely inform patients before surgery

By using the philosophy of lean hospitals it is important to understand of the value stream, it is the source of many information, new ideas and changes for the better. According to Womack and Jones, this is “a collection of all the activities required to produce a particular product (…) in a process of three critical task-management challenges that arise in every activity: product design, Information management (…) and finally Physical implementation of production”[Graban 2011]. When referring to medical activities, product design will be patient diagnosis and treatment plan, information managements  will be the issuing of instructions to nurses and information about health status of the patient, patient’s disease history and instructions for further care and product realization will treatment of the patient.  Although lean hospitals and improvements have been discussed for many years in Toyota, health care continues to suffer from the acquisition of implementation model and usage of the improvements of lean hospitals comparable to Toyota’s factories. Every hospital that has found Lean Healthcare has changed its philosophy of work, accomplishments in this area, found Muda and introduced improvements. A medical facility is like a human organism that lives its own life; there are no 100% duplicated schemes but there is adapting to the hospital’s operating profile. Therefore, organizations operating in the medical industry are learning from one another, taking each other as a example, but it is difficult to implement uniform and duplicated mechanisms. The healthcare industry as an economy that is spending more and more money, should implement better solutions and lean management is a tool that may make a lot of money and improve the competitiveness of the institute [Graban 2011].

1. Graban M., 2011, Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, ProdPublishing, Wroclaw
2. NHS Institute for Innovation and Improvement, 2012, Productive care case studies, staff improvements and leadership, South West, Poole Hospital http://webcache.googleusercontent.com/search?q=cache:PlA1mHDzkWkJ:system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx%3Fpath%3DStroke%252FNational%252Fwebsite%252FGoing_up_a_gear%252FPost_Hospital%255B1%255D.pdf+&cd=3&hl=pl&ct=clnk&gl=pl,
3. Putting patient first ,The productive series, 2012, NHS Institute for Innovation and Improvement, Case study 2, http://www.institute.nhs.uk/images/documents/Productives/Putting%20patients%20first%20-%20The%20Productive%20Series%20FINAL.pdf
4. Putting patient first ,The productive series, 2012, NHS Institute for Innovation and Improvement, Case study 3,
5. Streamlining Remittances to Improve One Hospital’s Cash Position, 2012, Healthcare Performance Partner, Case study 1, Xhttp://www.leanhealthcareexchange.com/wp-content/uploads/2011/03/HPP_CaseStudy_Remittance.pdf,
6. Improving Satisfaction and Reducing Waste through Visual Management, 2012, Healthcare Performance Partner, Case study 2, http://www.leanhealthcareexchange.com/wp-content/uploads/2011/03/HPP_CaseStudy_Nursing_Satisfaction.pdf
7. OR Tracking Event Answers Question : “Where’s my patient?”, 2012, Healthcare Performance Partner, Case study 3, http://www.leanhealthcareexchange.com/wp-content/uploads/2011/03/HPP_CaseStudy_OR_PatientTracking.pdf,
8. Hospital Streamlines Medication Delivery, 2012, Healthcare Performance, Case study 4, Partner,http://www.leanhealthcareexchange.com/wpcontent/uploads/2011/03/HPP_CaseStudy_Pharm_Delivery.pdf