Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.
“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”
At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.
Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.
Complacency is the Enemy
Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.
Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”
Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.
Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”