Part 1 of Q&A with Mark Graban, Author of Lean Hospitals

This is the first part of our question & answer session with Mark Graban, author of Lean Hospitals. Mark has been kind enough to take the time to give us thoughtful and in-depth answers. Here is the first installment of 8, with 12 more to follow this week:

Q1: Has lean become a mainstream phenomenon for hospitals yet, and if so
what percentage of hospitals are seriously engaged in implementing lean?


I saw one study that put both Lean usage and Six Sigma usage at about 20% for U.S. hospitals. I think that might be about right. But, it depends on what you mean by “using Lean.” That 20% figure could include those who are just dabbling with 5S in a single department to those, like Virgina Mason Medical Center and ThedaCare, that are embedding Lean into their culture and organizational strategy.

To your question about “seriously engaged,” I’d guess that it is probably 10% or maybe less. I wish we had better data on that. There are about 5,000 hospitals in the U.S. That’s a lot of potential Lean sites. Lean is, however, being implemented all throughout the world. The people registering for the free first chapter of my book come from every continent. I’ve been to conferences where I’ve met people from New Zealand, Canada, the UK, Italy, and Malaysia… this is a widespread movement, even if it’s not yet “mainstream.” But we’re making progress. We are moving beyond the era of people saying, “This can’t work in healthcare.” It’s proven that it can work, there’s no doubt about it.
Q2: Given the complex interaction of payer, patient, physician and
hospital staff, how does the lean notion of “respect for people” differ
within a hospital as compared to a manufacturing company?

I think “respect for people” applies just as broadly as it would at Toyota — to employees, suppliers, customers, and the community at large. Before Lean or without Lean, hospital leadership sometimes forgets this “respect for people” principle and can be just as numbers-driven as any industry (focusing on cost-cutting through layoffs). Lean gives an alternative — that costs can be reduced through quality and process improvement, much of which is driven by staff members.
Most of the individuals in healthcare care deeply about serving patients, but that doesn’t always translate into how leaders or organizations, as a whole, operate. When implementing Lean, we teach leaders to practice “respect for employees” — by making sure they are not overburdened and that their ideas are listened to, for example. Many of the quality and safety improvements are done in the name of “respect for patients” as the ultimate respect is shown by improving systems that could otherwise harm patients, if not improved upon or error proofed.

Q3: How would you characterize the level of waste awareness among
healthcare professionals, before being introduced to lean? How about
after being introduced to lean principles?


One on level, healthcare employees at all levels are very aware of the waste they deal with and fight through every day. They normally wouldn’t call it “waste” before being introduced to Lean terminology, but they are aware of inefficiencies, suboptimization, and frustrations. Frustration levels in hospitals are very high — because of broken systems and epidemic waste. But, people more often than not workaround the problems or fire fight — in the name of caring for patients or solving problems in the short-term, but at the expense of fixing the system or processes in the long-term. People end up fighting the same fires day in and day out, which wears on you.
One thing we do is to introduce staff members to the difference between “activity” or “motion” and value added work. We have to get them to recognize that not everything they do in their workday is value added, from a customer/patient perspective. Teaching them to focus on reducing waste (instead of gaining efficiency by working harder) is a very powerful notion. Once introduced to Lean principles like this, they learn to focus on identifying and eliminating waste, making their jobs less frustrating and freeing up time for patient care. Identifying it as waste is an important first step — but you also need leadership support to help people actually reduce the waste through process improvement.

Q4: I am curious that you classified waiting time as “non value added”
in Table 3.3 even though in the eyes of the customer it is clearly
waste. Can you explain?


Yes, waiting is clearly waste and NVA from the patient perspective. I wasn’t trying to implyotherwise.
By “non value added”, at that point in the discussion, I’m only talking about two categories: “value added” and “non value added” (or “waste”).
We also sometimes break NVA into “NVA but required” and “NVA, pure waste,” so we end up with three categories. Some activity does not directly add value to a patient (such as registration), but is required. Waiting is waste, or NVA, you could call it pure waste. I’m sorry if that was confusing… and hopefully I’ve helped clarify that.

Q5: In manufacturing settings overproduction is classically seen as the
mother of all wastes. What is the equivalent waste in hospitals?


You’re right to assume that overproduction isn’t as common in hospitals (or as critical), compared to factories. It can be found, such as collecting more blood specimens from a patient than might really be needed for testing (“just in case” tubes), but most healthcare work is done “on demand” or on a “pull” basis. We can’t build up an inventory of heart bypass procedures, for example.
Is there a mother of all wastes in healthcare? I think it’s probably the waste of defects — either defects that harm patients or defects in the process that lead to workarounds and extra work being created without the root cause being solved. That workaround waste perpetuates the cycle of 1) we’re too busy to fix things and 2) so things get worse… go back to #1. Getting people to stop the fire fighting cycle brings huge benefits in healthcare.


Q6: Which types of kaizen have had the biggest impact on patient
satisfaction in your experience?


Patient safety and quality improvements are greatly beneficial to patients, but preventing the error that never occurred is unlikely to increase satisfaction levels as evidenced in surveys. It’s hard to appreciate or be thankful for the prevention of an error that you would have never assumed would exist (such as an otherwise preventable infection occurring because a hospital staff member didn’t follow the proper procedure for inserting a central line).
Improvements that reduce waiting times can bring dramatic improvements in patient satisfaction. One hospital I’m working with has used Lean to increase throughput in outpatient radiology, bringing down waiting times to get in for an appointment, increasing access to care. We expect this will increase patient satisfaction. On other levels, hospitals that can reduce Emergency Department waiting time (waiting once you arrive) bring patient satisfaction improvements too. In one other really interesting case, a hospital improved patient satisfaction scores by using Lean to improve food services for inpatients – reducing batching and wasted food, using the savings to invest in better ingredients and fresher food. This hospital also was able to cancel a multi-million dollar construction project for a new food services building. The Lean improvements were certainly better for all stakeholders — patient, employee, and hospital.


Q7: You included “waste of talent” as the 8th waste in addition to the
original seven wastes. The other seven types can be easily be observed
or quantified, but how can this so-called 8th waste be observed?


The 8th waste can be seen in two primary areas. First, when staff members are not engaged in improvement efforts, that’s a waste of their talent. Healthcare professionals are smart, capable problem solvers. But, it’s heartbreaking when nurses or other staff members say things like, “I’ve worked here for six years and nobody’s ever asked me what I think,” or when employees who try to improve a process get labeled as “troublemakers” by managers (sad, but true, stories).
The second example is when highly skilled professionals are doing work that could be done by lower skilled or lower paid employees. If Medical Technologists are moving tubes of blood around the lab, when Laboratory Assistants could be doing that work, it’s a waste of the MT’s talent. If a Nurse is cleaning a room when a Technician could be doing that work, it’s a waste of the Nurse’s talent. With shortages of many key employees (like MTs and RNs), hospitals must maximize the use of the most technically skilled personnel.
I would draw a parallel to an assembly line, where material handlers do NVA work (moving parts) to the line so the value-added workers can focus their efforts on building product instead of running around chasing parts. Some factories make a major error in eliminating the material handler roles since they aren’t “value adding.” You often have an overall lower system cost by paying some people a lower wage to support those who make more. The same is true in hospitals.

Q8: Have you been able to quantify the reduction of the 8th waste within
hospitals?


One way you can quantify the percentage of time that a staff member is spending on non value added activities. In a number of published studies, the baseline for nurses in a hospital is that they only spend 30-35% of their time at the bedside with patients. There is a lot of avoidable waste in the remaining time. I have seen almost the exact same numbers in my own personal observation at another hospital (where I am starting a Lean project in November). By using Lean methods, nurses can spend 60% of their time providing care, checking on patients, or talking with patients. There are strong correlations between time at the bed side and quality and patient safety outcomes. In the UK, they have a national program called “Releasing Time to Care” that emphasizes that waste reduction and the time freed up will be reinvested in direct patient care (rather than cutting staff).
You can also quantify employee turnover and unplanned sick days. When employees are stressed from being overburdened or having a chaotic work environment, they are more likely to get sick or just call in sick. One hospital I worked with very quickly reduced unplanned absences from over 10% to about 3% — through staff engagement and involving them in continuous improvement. What had been historically and consistently high absenteeism was brought back in line with overall hospital numbers. If we can eliminate waste and improve processes, employees are less likely (I would assume) to altogether leave a field like Nursing. When we have shortages of key staff members, we can’t afford to have them quit and find a new professional out of frustration within the first few years of their career.

Please add your follow up questions or comments. And check back again on how you can win a copy of the Lean Hospitals book.

11 Comments

  1. Tom Wells

    October 6, 2008 - 2:21 pm

    Hi Mark,
    Thanks for your in depth answers and sharing from your experience.
    I especially like the explanation of the “8th waste” and concrete examples
    I guess lack of improvement suggestions would be a example of “waste of talent?”
    But using a higher skilled person to do a lower skilled job could also be overprocessing waste.
    Looking forward tomore.
    Tom

  2. Mark Graban

    October 6, 2008 - 3:11 pm

    Tom — Yes, you’re right that lack of improvement ideas is indeed a “waste of talent.”
    I wouldn’t categorize a Nurse doing work that a Nursing Assistant could do as “overprocessing.” I think “overprocessing” is defined by work that is done but doesn’t provide value to the patient or work done to a level of detail that doesn’t provide value.
    One example of overprocessing is people time/date stamping forms consistently… only to find that the data isn’t used by anyone for process improvement. You’d either want to stop doing the time/date stamping (or better yet, make use of the data). I’ve seen that happen a number of times.
    On another level, any care (diagnostics or meds) that doesn’t help a patient could be called “overprocessing.” I hate to go there, since I’m not a clinical person, but an obvious example might be prescribing an antibiotic for someone with a viral flu.
    Thanks for the comment!!
    Mark

  3. Anon

    October 6, 2008 - 3:39 pm

    Lean won’t work in hospitals. Doctors are too arrogant. Administrators aren’t business-minded. Nurses are OVER worked. The process flow is unstable. Each patient is unique. Maybe lean can add some short term relief to screwed up processes (there are many!) but it will not redesign health care delivery. No harm in trying? I don’t know…

  4. Mark Graban

    October 6, 2008 - 3:48 pm

    Anon — what’s the source of your frustration over this? Lean *does* work in hospitals. Is it a cure-all or a silver bullet for all that ails the industry? Of course not…. but not trying… will that make life any better for the nurses?
    I’d say there’s no harm in trying with Lean.
    “Each patient is unique” doesn’t mean that a hospital completely redesigns its processes for each unique patient. Right? Food for thought.
    Mark

  5. Jon Miller

    October 7, 2008 - 7:54 am

    Thanks for your comments!
    Please keep them coming as we continue the Q&A on Wednesday.
    You have the chance to WIN A FREE COPY of Mark Graban’s book Lean Hospitals.
    Just participate in the discussion of Lean Hospitals (similar to the comments above) this week and you have a chance to win.
    Tom and Anon, you are entered in the contest also, but to win and receive your book you will need to post a comment that includes your e-mail.

  6. Chris Nicholls

    October 8, 2008 - 1:38 am

    Dear Jon
    I haven’t thought about Lean Hospitals but the issues raised in Mark’s Q&A are very interesting because of the links drawn between Hospital processes and Manufacturing.
    Unfortunately I had an experience of the UK National Health Service myself only last week. My wife was stuck by her horse and I was concerned that she might have fractured her forearm. I took her to the local accident and emergency unit at our nearest hospital. The whole process took 6.5 hours but the actual value added process time was about 30 mins the rest was Muda mostly waiting time. We arrive at the hospital and take a ticket from the machine on the wall just like the deli counter at a supermarket (I was a bit impressed at this point). We waited until the Triage nurse makes an assessment ( 2 mins value added) and we are moved to another waiting area to register. Registration is very important so we had another 2 mins value added. The next step is to go wait in another waiting area until its your turn to see the doctor. After 2.5 hours we are shown into a treatment room. You guessed it we had another wait until the doctor showed up. The doctor arrived and gave my wife’s injury a thorough examination (value added). But then because an x-ray was necessary we were put in another waiting area until an x-ray was taken (value added). Following the x-ray we were asked to wait in yet another area until the doctor got a chance to review the x-ray result and decide any future treatment. Luckily my wife’s arm wasn’t broken. it seemed to me that the bottleneck was the doctor only one doctor on duty at this time. I’m sure that improving our hospital services is a very complex and difficult task. I have experienced two extremes of the heath service in the UK ranging from the experience I just described to the exemplary treatment my son received following a car accident
    Anyway I look forward to reading more of Mark’s Q&A on the subject.
    Best Regards

  7. Rob

    October 8, 2008 - 8:58 am

    Healthcare organisations in Canada and the US have been the first to introduce lean thinking, and there is top management support for it in some of the major healthcare organisations in these countries such as the Mayo Clinic, in Rochester, Minnesota, and the University of Colorado. There is also a plethora of practical case studies from them that demonstrate lean thinking’s successes.
    As a result, several NHS trusts such as Wirral Hospital NHS Trust, Merseyside, are currently introducing lean thinking in their efforts to streamline services.
    In the book, “Lean Six Sigma for Service”, there is an outstanding case study from Stanford Hospital and Clinics in which they have seen a drop in the mortality rate of 48% as well as costs savings of 40% since using lean six sigma. Also Park Nicollet Health Services have begun using Lean and Kaizen within there CFO offices and have been seening great results from it.
    Successful promotion of lean health care across the UK depends however on gaining both the support of government and the NHS at executive level. If this is won, implementation of lean thinking at organisational level can be achieved by the strategic training of relevant staff members. The potential benefits of lean thinking are:
    * Shorter patient waiting times
    * More patient admissions and diagnoses
    * Faster bed turn arounds
    * Improved workplace organisation, cleanliness and safety
    * Less inventory used and better use of space
    * Better and more streamlined administration processes
    * More efficient patient record and appointment processes
    * More timely and efficient delivery of care
    * Better supply and storage management
    As the cost of health care continues to rise, the NHS is put under increasing pressure to reduce costs while improving patient safety and care, and reducing errors and the resulting litigation.
    New discoveries in medicines are being made, and new treatments are being developed, at a rapid pace, but these will be no more important to healthcare services in the future than the results of lean thinking.
    The associate chief of staff of mental health services at the University of Arkansas for Medical Sciences Jeffrey Clothier offers a glimpse of this future when he comments on how services are commissioned and used: ‘Some systems already allow patients to go online and select their appointment time without ever speaking to a clerk. The services they pull will be those that have value for them. Lean will provide the basis for understanding the value-added activities that will compose personalised medicine.’
    Applying lean thinking to the healthcare sector can provide significant cost and process efficiencies. However, to realise and sustain these benefits fully, there is an urgent requirement to educate and empower healthcare staff in the principles and methodologies involved. Education and training in lean thinking should be part of organisations’ competency frameworks to ensure consistency across all functions.
    Relevant links:
    http://www.childrensmn.org
    http://www.vha.com
    Read this story:
    http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande
    and then follow up with this one:
    http://www.bioethicsinternational.org/?p=416
    Please consider the following excerpt from the bioethicsinternational.org post:
    The Unbelievable News
    On December30, the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that the administration has brought a halt to the life-saving checklist program both in Michigan and at Johns Hopkins:
    ”this past month, the Office for Human Research Protections shut the program down.,” Gawande writes. ”The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.
    “The government’s decision was bizarre and dangerous,” Gawande adds. ”But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.
    In summary: we are the enemy when it comes to process improvement.
    Rob

  8. A believer

    October 8, 2008 - 6:11 pm

    Using lean in the medical labs, both in hospitals and commercial lab companies is a really good idea. I used to work for a commercial lab company that implemented lean methods in the lab and has begun to see some good cycle time reductions for their high volume tests.

  9. Mark Graban

    October 9, 2008 - 5:57 am

    To “A believer” — you’re right, Lean is really helping to transform many medical labs. Laboratories are probably the “early adopters” of Lean in hospitals, so they deserve a lot of credit.

  10. anjilinjones

    October 10, 2008 - 3:00 am

    hand-washing policies to prevent the spread of antibiotic-resistant infections. This should be frightening. You would hope the results would be better coming from hospitals that volunteered to be surveyed on the topic. With the recent push from hospital quality experts to utilize LEAN methods and the attention of IHI, AHA, CMS and others on the topic, why do so many hospitals struggle with Safety.
    ——————-
    jones

  11. Mark Graban

    October 10, 2008 - 8:35 am

    It is frightening when different studies show between 30 and 50% compliance on proper handwashing — people coming in and out of patient rooms.
    It’s more complicated than needing awareness or needing more policies. We need hospitals to manage work and eliminate waste so that people have time to do the work the right way without being pressured into taking time-saving “shortcuts” that don’t serve the patient well.