Lean Methodology: Driving Better Care, Happier Providers

Lean methodology, adopted from the Toyota Production System which was originally conceived after World War II, has been hailed as a way to save costs, streamline efficiencies and reduce waste in virtually any endeavor. Healthcare has been slow to adopt the strategy, but those organizations that have can attest to its value to patients and employees.

Lean at Mount Sinai

Mount Sinai Medical Center in New York City first implemented Lean management strategies in 2000. The organization’s efforts have only expanded since then, says Margaret Pastuszko, VP, strategic and business planning. The organization has been using the Kaizen approach to “help us identify opportunities quicker and react in a quicker fashion.”

Mount Sinai has a team of four senior people with a variety of Lean and engineering backgrounds plus an expanding roster of analytical support staff charged with continuously identifying opportunities to improve performance.  The group looks at everything from quality measures like infection rates and pressure ulcers to measurable outside quality areas such as how fast a blood specimen gets from the clinical area to the central lab. “The impact this team has had is amazing,” Pastuszko says. “Getting different multidisciplinary teams around the table to understand interdependencies and where bottlenecks are provides solutions.” 

Kaizen (Japanese for good change) projects are three- to five-day breakthrough events:
  • Standardize an operation and activities
  • Measure the operation (find cycle time and amount of in-process inventory)
  • Gauge measurements against requirements
  • Innovate to meet requirements and increase productivity
  • Standardize the new, improved operations
  • Continue cycle ad infinitum

The Kaizen approach is not a one-and-done strategy, Pastuszko says. “We really, truly believe in continuous process improvement. We continue to look for opportunities to be more efficient, more responsible, more friendly for patients and focus on quality initiatives. There is no limitation to the areas where we can use Lean principles.”

One effort has focused on improving the patient experience in ambulatory sites. “We look at the process of the patient from the moment he or she arrives until the moment he or she leaves and eliminate non-value-added experiences. Are patients waiting too long? Are they getting all the information they should be provided with?” Pastuszko says an additional challenge is the ability to measure patient experiences “because it’s very difficult to improve something you cannot measure. The measures are not always perfect but at least they are directional.”

In one ambulatory site, the Mount Sinai team reduced registration time by 60 percent and patient wait-time from registration to physician interaction by more than 50 percent. “These are significant numbers,” she says. The goal is to put together the entire matrix of the experience and maximize the overall experience rather than pieces within it. Opportunities to ensure optimal patient scheduling and eliminate time spent looking for pertinent information, and more, combine to improve the overall patient experience.

Pastuszko’s biggest challenge now, she says, is staffing all the proposed projects. “Opportunities are everywhere. Anyone can walk around and think ‘how can we make this better for our customers?’ Those customers include patients, staff, physicians, everybody. Everything can be addressed and improved.”

Lean in Arkansas

St. Bernard’s Hospital in Jonesboro, Ark., began using Lean management techniques in February 2011 both to improve its current performance on all fronts and prepare for the future of episodic payment, workforce shortages and other challenges.

Susan Greenwood, vice president of quality, safety and risk management, and others took a Lean certification course but they also engaged a consultant—a move she highly recommends. “We can’t fix something we created ourselves. We don’t necessarily have the vision or skill set. If we did, we wouldn’t be in this mess in the first place.”

A facilitator can help shift the focus from managers to frontline workers, she says. “In healthcare, we have a tendency to consider the benchmark. What are other hospitals doing? That doesn’t matter because the benchmark is terrible.” Greenwood says St. Bernard’s was clear from the beginning that they wanted the consultant to teach them the skill set and provide an exit strategy. “If you become reliant on a consultant then you never really embed Lean in the culture.”
Lean targets waste—find it and eliminate it. For example, St. Bernard’s medical management value stream mapped the whole process to find waste. The Lean team achieved several critical outcomes: reduced the time from chart check to medication administration by 64 percent, improved availability of medication from 82 percent to 99 percent, eliminated four medication pass times each day to save 72 minutes a day of nursing time and reduced pharmacy re-dispenses by 27 percent.

Efforts have saved $1.6 million which paid for construction work to redesign nursing stations for efficiency and the consulting firm. While everyone feels great about that figure, she says, Lean is not just about finances. “It’s working on satisfaction, quality and time. Lean projects take steps away so employees are so satisfied,” Greenwood says. The savings also has allowed the organization to reinvest in technology and people.

Doing two jobs

8 Types
of Waste
(non-value added)
  • Defects
  • Over-Production
  • Waiting
  • Not clear
  • (Confusion)
  • Transporting
  • Inventory
  • Motion
  • Excess Processing

Eric W. Dickson, MD, MHCM, first turned to Lean principles when he started as director of an emergency department in the Midwest. He became well-versed with Lean and brought the management techniques to UMass Memorial Healthcare in Worcester, Mass., when he joined the organization in 2008.

There already was some interest in Lean at UMass and within a couple years of his arrival, the organization built a dedicated department. “We created that core group of people who could go out and help others in the organization learn, a core group to support Kaizen projects. That’s important in Lean. Nobody swoops in and fixes things for you. You own that challenge as a person and a team. It’s been remarkable to watch.”

Everything changed for the better, he says, with Lean. Care got better and “the people doing the work got greater joy out of coming to work every day,” Dickson says. “[UMass] became not only a better place to be a patient, but a better a place to be a nurse, a doctor or a manager.”

Lean means everyone has two jobs—to do their job and to try to do their job better. At UMass, Dickson created a process for that. The core philosophy is that the people doing the frontline work understand the problems better than management and can come up with better ideas to solve those problems than management can. “That way you end up with an army of innovators on the front line,” he says.

For example, a triage nurse requested a row of chairs right by registration so that she and her triage colleagues wouldn’t have to get up and call for patients in the waiting room each time. When one patient is being registered, the next patients can sit and wait right there and the triage nurse never has to get up.

“A little idea like that saves just two or three minutes per patient but, over the course of an eight-hour shift with 50 to 60 patients, it makes all the difference in the world,” Dickson says. “In a million years, I would never think of that because I don’t do the triage job. The nurse doing triage is the only one who can think of that time saver.”

Savings also came in CT contrast. For years, UMass Memorial had injected two bottles of 250cc contrast into each patient undergoing a CT scan. The radiologic technologists suggested buying 500cc bottles to save time and money. “Again, a radiologist or radiology manager would never recognize that because they are not hanging up those two bottles,” Dickson says.

Lean challenges

Despite the efficiencies that can be achieved, there are challenges to implementing Lean methodology. “Corporate and executive management buy in and leadership is critical,” says Pastuszko. “Otherwise, all efforts will fail.”

To start successfully implementing Lean methodology at your organization, Dickson says don’t ask people for ideas on how to cut costs. “Talk to physicians. Ask them what frustrates them and what wastes their time and work to solve those problems first.” Successes among the frontline workforce, especially doctors, will get people on board with the effort. “Start with ‘how can I make this a better place for you to work?’ Institute ideas around that because, fundamentally, it comes down to making it a great place to work.”

While the executive management must provide sponsorship for Lean to work, says Pastuszko, the “right team is needed to facilitate this.” The best team “believes fundamentally that change is good and that opportunities can present themselves everywhere.” The team needs to work with people on the front line in a collaborative manner. “Collaboration makes this successful.”

Projects are centered around continuous improvement and don’t “carry glory or acknowledgement in a lot of areas,” Pastuszko says. Organizations need to “fundamentally believe that this is the way business has to evolve.”

Organizational leadership needs to support teams and “remove barriers so they can do the work,” says Greenwood. “Get the frontline staff engaged. Communicate, communicate, communicate,” she advises. “You can’t talk about it enough. Sing the praises of the Lean team so that everybody starts to talk about it.” Greenwood says employees will start to request events to drive performance improvement in areas they know are going wrong. “That’s when you know you have an embedded Lean culture.”

Lean culture needs to be more pervasive in healthcare for several reasons. “There are true returns however you measure it—patient experience, quality, financial,” says Pastuszko.

Those organizations whose competition adopts Lean methodology may find themselves falling behind, says Dickson. “Lean organizations deliver by process. If we continue to deliver by numbers, we’re going to be in trouble.”