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.

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