Applying Flow to Healthcare

The consultants in our Lean Healthcare practice are speaking with an increasing number of hospitals and healthcare organizations interested in Lean. As we all know, healthcare costs are high and patient wait times are long. Anyone who has had experience sitting in a waiting room, examination room, or in a hospital bed can attest to the fact that there is a distinct lack of flow in the way healthcare is provided today.
One of the key ideas in Lean is to increase velocity, or the amount of profit generated over a period of time. Velocity is increased by examining the revenue generating sequence of activities called Value Streams. When waste such as delays, errors, transportation, motion, and so forth are eliminated from these operations what remains is the ability to provide the same value in less time. Flow is the key to increasing velocity.
Assuming that assets such as beds, medical equipment, and surgery rooms are fixed, the revenue generated through these over a set amount of time must increase. We usually can not add resources without spending money. We can not increase the amount of time available to us in a 24 hour day. We must increase velocity by speeding up the flow of value through the system. This is done by examining and eliminating the non value-added and Muda (waste) elements of the process of providing care.
What is the impact of better patient flow for hospitals? As waiting time is reduced, the healthcare experience for the patient improves, reducing waiting time and speeding recovery. As patients flow from process to process (from sickness to health) beds turn faster, and more patients can be served. More patients served equals to more revenue for the hospitals. By increasing revenue with the existing fixed costs (rooms, beds, overhead) hospitals can increase profitability.
The first step is to identify the healthcare value streams that are the target of conversion to flow by asking the following questions of process and service mapping: What types of care does the hospital provide? What volumes of patients are experienced for each? What are the resources needed for each? What is the sequence of steps to provide care?
Then, we design a just in time system through a relationship of one-piece pull of work (patients, samples, x-rays, etc.) at the pace of customer demand (takt time). We do this through a live simulation by walking a patient through the process of care without delay, one at a time. The results are documented, challenges and problems are identified, and a system to support smooth patient flow is defined.
The rules to follow for smooth patient flow are the same as those of the Toyota Production System:
#1: Specify timing, sequence, and outcome of all work
#2: Connect all customers and supplier relationships with one-piece pull
#3: Flow product or service directly one at a time
#4: Signal problems at each step through stop the line
#5: Start at the process owner solve problems using the scientific method
There are three main problems likely to be encountered with patient flow at any hospital. These are 1) scheduling, 2) inflexibility of the layout of hospital facilities, and 3) the functional or silo mentality between departments.
1) Smoothing out schedule of capacity of value streams across capacity constrained resources, such as operating rooms, is a theme common to all Lean implementations. One example of a barrier to flow is the lack of beds. One root cause of slow turns of beds is a delay in discharge. The root cause can be something as simple as scheduling discharge times at the convenience of the physician rather than based on the pace of customer demand or a target turn time for beds.
Not having a bed available creates the waste of waiting for the patient, motion for the nurses who must search for an available bed, transportation for the patient who must be relocated to the bed, and extra processing to make sure the charts, meds and resources are diverted to the new location. A common goal must be set to improve patient flow and increase velocity so that competing interests can be resolved and behaviors can change.
2) Compared to a factory layout where equipment and even non-structural walls can be moved with ease to accommodate improved flow, hospitals tend to be multi-story, multi-building structures with complex infrastructures that do not lend themselves to a quick rearrangement processes to accommodate patient flow. Although the best opportunities are to take advantage of new construction or remodeling, we are seeing hospitals that are willing to remove physical walls and convert room, offices, and storage space to accommodate patient flow.
3) As in any industry, a strong silo mentality exists in hospitals between the facilities a hospitals provide, physicians, specialists, RNs and staff all trying to optimize their part of the value stream of providing care without looking at it from the perspective of the patient. This must be addressed long-term through a team approach and conversion to value stream management.
Patient flow is an exciting area of Lean Healthcare, as it holds the promise of lower costs, improved quality of care, and a better patient experience for all of us.

4 Comments

  1. sharifi moslam

    December 12, 2004 - 12:27 am

    hi iam an iranian steudentin health care m
    anagement in tehran university
    i want some article or research about “implementation of kaizen in hospital”
    thank,s

  2. serhat

    September 16, 2006 - 1:02 pm

    I want to some article and reseach about implementation of kaizen in hospitals.
    thanks
    family medicine serhat hacimusalar

  3. Jon Miller

    September 18, 2006 - 6:26 pm

    Hello Serhat,
    Thank you for your question. You can find articles and information about kaizen in hospitals on our website.
    Best of luck,

  4. Emran

    January 6, 2007 - 9:54 am

    I want to some article and research about implementation of kaizen in hospitals.
    thanks