Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.
“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.
Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.
“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.
When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.
Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”
Lean Solutions
Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.
Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.
“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”
Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”
One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.
In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.
Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”