The Lean Hospital:
What does it mean?
Kristin Furfari, MD
Outline
• Waste in the US Health Care System
• Lean principles: The Toyota Method
• Application to hospital medicine
• Discharge throughput: A UH example
Disclaimers
Per Capita Health Care
. (US$PPP)
Spending
$6,000
$4,887
$5,000
$4,000
$3,322
$2,808
$3,000
$2,792
$2,561
$2,131
$2,000
$1,992
$1,000
Ki
ng
do
m
Un
i te
d
Ja
pa
n
an
ce
Fr
Ca
na
da
m
an
y
Ge
r
la
nd
Sw
itz
er
Un
i te
d
St
at
e
s
$0
Source: Organization for Economic Cooperation and Development, OECD Health Data 2002
$1,800
$1,600
$1,400
National Health
Expenditures
(in billions)
$1,200
$1,000
$800
$600
$400
(1)
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
$200
Inflation-adjusted
Source: Centers for Medicare & Medicaid Services, Office of the Actuary
(1) Expressed in 1980 dollars; adjusted using the overall Consumer Price Index for Urban
Consumers
20%
18%
National Health Care
Expenditures as a Percent
of GDP
16.0%
16%
14%
12%
13.4%
13.1%
13.2%
1993
1996
1998
14.9%
15.4%
2002
2004*
18.7%
10.9%
10%
8%
6%
4%
2%
0%
1988
2006*
*Projected
Source: Heffler et al., “Health Spending Projections for 2004–2014,” Health Affairs (February23, 2005).
2014*
Institute of Medicine Report on
Medical Errors
50,000-100,000
deaths annually
950,000 patients
injured annually
$15 billion-$30 billion
in cost
Wasted Time for Hospitalists
Direct Patient
Care18%
Indirect
Patient
Care
69%
Direct Patient
Care
Indirect Patient
Care
Professional
Development
Education
Travel
Personal
Percentage Breakdown of Time
Waste in healthcare
“The national numbers for waste in
healthcare are between 30% and 40%
but the reality of what we’ve observed
by minute-to-minute observation over
the last three years is closer to 60%....
It’s everywhere: patient care and nonpatient care alike.”
The Problem
• Too little efficiency
• Too much waste
Toyota Production System
• Largest manufacturer in the world
• Eight times more profitable than the
industry average
• Produced 40% of the “most reliable” car
models on the market in the last decade
Toyota Production System
• Taiichi Ohno: Father of the TPS
• Developed his ideas from observing:
The Indianapolis 500
The River Rouge plant
American supermarkets
Toyota in Healthcare
• Creating an environment of stability
• Elimination of waste
• Rapid identification and correction of
errors
What is Lean Thinking?
• A methodology to produce the highest
quality product in the shortest amount
of time, at the lowest possible cost by
eliminating the “seven wastes.”
• Fosters a culture which encourages all
employees to continually look for
improvement
The “Seven Wastes”
•
•
•
•
•
•
•
Waste of Overproduction
Waste of Time (waiting)
Waste of Product Transport
Waste in Excess Processing
Waste in Inventory
Waste in Movement
Waste in Producing Defects
The “Seven Wastes”
• Waste of overproduction
Separate intern, resident, attending, social
services rounding cycles
Entering repetitive information on multiple
documents or forms
• Waste of time on hand (waiting)
Primary team waiting for support services
Patients waiting to make followup
appointment
Delays for bed assignments
• Waste of processing
Multiple computer programs to document
patient care information
Ordering more diagnostic tests than the
diagnosis warrants
Retesting
• Waste of stock on hand (inventory)
Duplicate medications and supplies in
excess of normal usage
Unnecessary instruments in operating room
kits
Obsolete charts, files, equipment, paperwork
• Waste in transportation
Primary team traveling to different floors to
see patients
Waiting for transportation to arrive to take
patient to testing, surgery, discharge
• Waste of movement
Nurses leaving patient rooms for common
supplies
Searching for charts, patients, medications
• Waste of producing defects
Iatrogenic illness
Medication errors
Understanding Value
• Understand value as defined by our
customers
Patients, families, payers, regulators
Physicians, nurses, hospitals
High-quality, safe, efficient,
appropriate
Understanding Value: Lowry Clinic
• Check in at front desk
• Wait in waiting room
• Walk with nurse to
assessment room
• Nurse takes vitals
• Walk to exam room
• Wait for physician
• Physician exam
• Wait for physician to
return
• Physician consult and
treat
• Wait for nurse follow-up
• Walk to laboratory
waiting room
• Wait for labs
• Get labs drawn
• Check out
Toyota Production System
University of Colorado Hospital - As-is Credit Process Map
Payment posting
No
Is there a
credit
balance?
Payment posted
to account
Yes
Is the balance
over $1,000?
Yes
Print screen
Give to credit
analyst
Research (*)
Credit analyst
waits for EOB
END
Refund Clerk
No
Run weekly
credit balance
report
(on Monday)
Download to
excel
Manipulate excel
based on criteria
(if 2 adj - reverse
if 2 pmts - refund
etc.)
Batch with EOB
Print excel form
Complete excel
form
(1 form per
refund)
Create batch in
HPA
(group of 25)
<$50K per
account?
Management
No
A/P
Vendor in
system?
Yes
Refund
appropriate?
No
- Value Enabling
Process reverse
adjustment
- Value Add
Print batch
header
Bundle up EOBs,
batch header,
excel form
Deliver to A/P
Yes
Yes
Billing Office
Manager sign-off
Post transactions
Yes
- Non Value
Supervisor signoff
25 refunds?
Write vendor# on
excel form, key
visit, $, date, G/L
into Lawson
Does batch
balance?
No
No
Add vendor (ins
co) or temp#
(patient) on the
fly
Audit batch / fix
Audit checks vs.
paperwork
Scan checks and
paperwork
Yes
Release batch for
printing
Checks printed
(next day)
Copy of 2nd copy
of check made
for Billing Office
Checks
distributed
Toyota Production System
Payment posting
University of Colorado Hospital - To-Be Credit Process Map
Payment posted
to account
END
Run weekly
credit balance
report
(on Monday)
Download to
excel
Research (*)
Refund Clerk
- Non Value
- Value Enabling
Refund
appropriate?
NO
No
- Value Add
Billing Office
Manager sign-off
Management
Billing Office
Manager sign-off
Refund
appropriate?
YES
Billing Office
Manager sign-off
Research (*)
Download to
excel
Billing Office
Manager sign-off
Vendor in
system?
A/P
Research (*)
Yes
Write vendor# on
excel form, key
visit, $, date, G/L
into Lawson
Download to
excel
Download to
excel
Does batch
balance?
No
No
Add vendor (ins
co) or temp#
(patient) on the
fly
Audit batch / fix
Yes
Release batch for
printing
Checks printed
(next day)
Copy of 2nd copy
of check made
for Billing Office
Checks
distributed
Process Improvement
Preparation
Current state
Future state
Implementation plan
Kaizen
Kai: “Take Apart”
Zen: “Make Good”
The Lean Week
Pre-Lean
Identify, map and measure current process
Lean Week
Mon
Tues
Wed
Thurs
Fri
Learn tools
Develop solutions
Go-live
Post-Lean
Monitor, measure, control, close
Standardization
• Standardization is the basis for
continuous improvement and quality
– Repeatable, stable methods provide a
predictable, regular output
– Creates a safe culture to point out
problems and a standard way to fix them
Standard Work
• The technique of achieving consistent
performance by creating a consistently
applied method of doing a task
• The creation of the method by the
people doing the work
• Should lead to continual improvement
Standardization
“Today’s standardization…is the necessary
foundation on which tomorrow’s
improvements will be based. If you think of
standardization as the best you know today
but which is to be improved on tomorrow—
you get somewhere. But if you think of
standards as confining, then progress stops.”
Henry Ford, 1921
Virginia Mason Medical Center
• Ventilator-associated pneumonia
35
30
25
20
Cases
Deaths
15
10
5
0
2002
20004
Pittsburgh Regional Healthcare
Initiative
150
120
Central LineAssociated
Bloodstream
Infections
90
60
30
2001
2002
2003
2004
University of Michigan
• PICC lines placed within 24 hours of
request:
– Initially: 50%-70%
– After Lean: 90%-95%
Overall 36% decrease in average time to
placement
12 West Lean Outcome Data
October 2008-April 2009
Percentage of Discharges by 2pm
100%
90%
84%
72%
80%
70%
60%
44%
50%
40%
30%
20%
50%
54%
42%
29%
22%
10%
0%
Baseline
Oct
Nov
Dec
Jan
Feb
Mar
April
Opportunities
• Identify and reduce waste in the 7E discharge
process
• Identify hospital system throughput delays
• Recommend process improvements for
hospital-wide discharge process barriers
• Understand how efficiency of the discharge
process affects patient satisfaction
Goals
• Reduced time from room empty to room occupied
• Double the percentage “clean to occupied bed time”
in less than 60 minutes from 22% to 44%
• Improve daily median discharge time by 1 hour for
Monday through Friday discharges
• Create a control plan to monitor and sustain
improvements
Baseline Data
Median Discharge Time by Day of Week:
10/1/09-12/31-09
1600
1500
Median Time of
Discharge
1400
1300
1200
M o nda y
T ue s da y
We dne s da y
T hurs da y
F rida y
Baseline Data
Clean to Occupied Bed Time:
10/1/09 – 12/31/09
Attending Physician
DC IV DC Home
orders are
w ritten
(note 1)
Flag the chart
yellow
Put chart on
rack
(note 2)
Put chart on
desk
(note 3)
Notif y
Nursing
Staff of DC
Stop
Yes
Call Doctor f or
clarification
No
Primary RN
Notified of DC
order
(note 4)
Discuss DC
Plan w ith
Patient
(note 6)
Yes
Orders
Complete?
Accurate?
(5)
Print instructions
f rom MicroMedex
Take
instructions to
patient room
(note 8)
Complete
patient
education
(note 9)
Remove IV
access
Patient Service Coordinator
Complete
nursing tasks
(note 7)
Hear sound of
chart being put
in rack
Review DC
order and
prescriptions
Page other
disciplines to
complete pt
care w ith
priority for DC
Call RN to let
him/her know
about DC
order
Highlight
patient's room
number on
assignment
sheet
Charge Nurse
Home Health Coordinator
Give
prescription
to patient
Yes
Tube
prescription
to Atrium
Pharmacy
Yes
Need
transport
to car
Order
Transport
Complete
Charting
Remo ve
patient fro m
Care M anager
(No te 10)
Tell Charge
RN patient
has been
discharged
Ask C.N.A.
to remove
equipment
f rom room
No
Let patient
w alk to the
car
Stop
Put confirmed
DC in
Bedboard
Notify Primary
RN about DC
orders
Transcribe DC
order into Care
Manager
(note 11)
Place chart
back on rack
for RN to cosign
Record DC
inf o in Census
Book
(note 14)
Write DC in
Medical
Records log
(note 15)
Photo copy DC
paperw ork
File DC
paperw ork
copy
Breakdow n
chart
Enter OBS
charges in to
IDX
Write DC on
large w hite
board
Assist Primary
RN w ith DC if
RN is too busy
Remove
patient f rom
Care Manager
(Note 10)
Page other
disciplines to
complete pt
care w ith
priority for DC
Does pt
need home
health care
Yes
Review DC
paperw ork
(pink sheet)
for medical
needs
Complete
"home care
assessment"
(Note 12)
Review DC
paperw ork
(pink sheet)
for medical
needs
Fax pink sheet
to infusion
center
Compile
paperw ork to
send to
accepting
agency
Contact home
care agencies
Send
paperw ork to
agency
Stop
(16)
No
Stop
Yes
Case Manager
Prescript
ion filled
at UCH?
No
Does pt
need home
antibiotics
Yes
Does pt
need home
equipment
No
Call company
to set up
equipment
delivery
(note 13)
Stop
(17)
No
Social Worker
Stop
Determine
payor source
Get chart f rom
rack
Does pt
need SW
services
Yes
Contact SNF
about
placement
Talk to family
about w hat
they w ant
Copy chart
Arrange
transportation
Fax orders to
SNF
Call SNF to
update about
departure
time/needs
Stop
No
Stop
Yes Expedite meds
Do es pt
need inpt
meds befo re
DC
No
being
processed by
inpt pharmacy
Yes
Yes
Do es pt
have
prescriptio ns
to be filled
Counsel
patient on use
of certain
medications
Can pt affo rd
prescriptio ns
Stop
No
No
Pharmacist
Will patient
qualify fo r
CICP
Yes
Notify Social
Worker for
assistance
w ith CICP
registration
No
Yes
Do es pt qualify
fo r o utpt
assistance
pro gram
Contact
physician to
recommend
cheaper
therapy
No
Refer pt to
outpt
pharmacy for
assistance
EVS
Transporter
Receive page
fro m Care
M anager that pt
is ready fo r
discharge
Go to patient's
room
Yes
Will pt be
ready in 5
mins
No
Reschedule pt
pick up in
system
Take patient
off unit
Do es pt
need to go
to
Yes
Yes
Take patient to
pharmacy
Enter complete
code in phone
system
Receive page
w ith room
number
("dirty")
Take pt to car
Is wait at
pharmacy
less than 5
minutes
pharmac y
Enter job
completed in
phone system
No
Reschedule pt
pick up in
system
No
Go to patient
room
Log into phone
system ("in
progress")
Find someone
to remove
medical
supplies
Clean room
(45-60
mintues)
Log out in
phone system
("clean")
Stop
Phase II
• Compare staff interview and observation process
maps
• Meet with 7E staff to identify wastes in the process
and determine Kaizen events
• Implement solutions
• Monitor data compared to baseline/goals
• Create plan for sustainability of project
References
•
•
•
•
•
•
•
Berczuk, C. The Lean Hospital. The Hospitalist. 2008; June
Bush, RW. Reducing waste in US Health Care Systems. JAMA. 2007;
297(8): 871-874.
Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean Health Care: What Can
Hospitals Learn from a World-Class Automaker? J Hosp Med. 2006;
1(3): 191-199.
Liker JK. The Toyota Way: 14 Management Principles from the
World’s Greatest Manufacturer. McGraw-Hill: 2004.
O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their
time: insights on efficiency and safety. J Hosp Med. 2006; 1(2): 88-93.
Spear SJ. Fixing Healthcare from the Inside, Today. Harvard Business
Review. 2005; Sept: 1-14.
Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production
System. Harvard Business Review. 1999; Sept: 96-106.
Questions?