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
$6,000 Spending. (US$PPP)
$4,887
$5,000

$4,000
$3,322

$3,000 $2,808 $2,792

$2,561
$2,131 $1,992
$2,000

$1,000

$0

m
y
nd

ce
s

n
da
an
e

do
pa
an
at

la

na
m

ng
Ja
er
St

Fr
Ca
r
itz

Ge

Ki
d
i te

Sw

d
i te
Un

Un
Source: Organization for Economic Cooperation and Development, OECD Health Data 2002
$1,800 National Health
$1,600 Expenditures
$1,400 (in billions)
$1,200

$1,000

$800

$600

$400
Inflation-adjusted (1)

$200
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
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
 National Health Care
Expenditures as a Percent
20% 18.7%
18%
of GDP 16.0%
14.9% 15.4%
16%
13.4% 13.1% 13.2%
14%
12% 10.9%

10%
8%
6%
4%
2%
0%
1988 1993 1996 1998 2002 2004* 2006* 2014*

*Projected
Source: Heffler et al., Health Spending Projections for 20042014, Health Affairs (February23, 2005).
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% Direct Patient
Care
Indirect Patient
Indirect Care
Patient Professional
Care Development
69% 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 weve observed
by minute-to-minute observation over
the last three years is closer to 60%....
Its everywhere: patient care and non-
patient 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 for physician to

Wait in waiting room return
Walk with nurse to Physician consult and
assessment room treat
Nurse takes vitals Wait for nurse follow-up
Walk to exam room Walk to laboratory
Wait for physician waiting room
Physician exam Wait for labs
Get labs drawn
Check out
 Toyota Production System
University of Colorado Hospital - As-is Credit Process Map

No
Payment posting

Is there a
Payment posted Is the balance Give to credit
credit Yes Yes Print screen END
to account over $1,000? analyst
balance?

No

Manipulate excel
Run weekly
based on criteria
credit balance Download to Credit analyst
(if 2 adj - reverse Research (*)
report excel waits for EOB
if 2 pmts - refund
(on Monday)
etc.) - Non Value

- Value Enabling
Refund Clerk

Complete excel
form Refund Process reverse
Batch with EOB Print excel form Yes No
(1 form per appropriate? adjustment
refund)
- Value Add

Create batch in Bundle up EOBs,

<$50K per Print batch
HPA Post transactions batch header, Deliver to A/P
account? header
(group of 25) excel form

No Yes Yes
Management

Billing Office Supervisor sign- Audit checks vs. Scan checks and
25 refunds?
Manager sign-off off paperwork paperwork

Write vendor# on
Vendor in excel form, key Does batch
Yes Yes
system? visit, $, date, G/L balance?
into Lawson

No No
A/P

Add vendor (ins

Copy of 2nd copy
co) or temp# Release batch for Checks printed Checks
Audit batch / fix of check made
(patient) on the printing (next day) distributed
for Billing Office
fly
 Toyota Production System
University of Colorado Hospital - To-Be Credit Process Map
Payment posting

Payment posted
END
to account

Run weekly
credit balance Download to
Research (*) Research (*)
report excel
(on Monday)
- Non Value

- Value Enabling
Refund Clerk

NO Refund
No
appropriate?

- Value Add
Billing Office Billing Office Refund Billing Office Download to Download to
YES Research (*)
Manager sign-off Manager sign-off appropriate? Manager sign-off excel excel
Management

Billing Office Download to

Manager sign-off excel

Write vendor# on
Vendor in excel form, key Does batch
Yes Yes
system? visit, $, date, G/L balance?
into Lawson

No No
A/P

Add vendor (ins

Copy of 2nd copy
co) or temp# Release batch for Checks printed Checks
Audit batch / fix of check made
(patient) on the printing (next day) distributed
for Billing Office
fly
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
Todays standardizationis the necessary
foundation on which tomorrows
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
15 Deaths
10
5
0
2002 20004
Pittsburgh Regional Healthcare
Initiative
150

120

Central Line-
90 Associated
Bloodstream
Infections
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%
80% 72%
70%
60% 50% 54%
50% 44% 42%
40% 29%
30% 22%
20%
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:
1600
10/1/09-12/31-09

1500

1400 Median Time of

Discharge

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
 Put chart on
DC IV DC Home Flag the chart rack

Attending Physician
orders are (note 2) Notif y
yellow Stop
w ritten Nursing
(note 1) Put chart on Staff of DC
desk
(note 3)

Yes

No Call Doctor f or
clarification

Notified of DC Discuss DC Print instructions Take Complete Remove IV Yes

Primary RN

Orders Yes Yes Tube Order Complete Remo ve Tell Charge Ask C.N.A.
order Plan w ith f rom MicroMedex instructions to patient access Prescript Need patient fro m
Complete? prescription Transport Charting RN patient to remove
(note 4) Patient patient room education ion filled transport Care M anager
Accurate? to Atrium has been equipment
(note 6) (note 8) (note 9) at UCH? to car (No te 10)
(5) Pharmacy discharged f rom room

No No
Complete
nursing tasks
(note 7) Give Let patient
prescription w alk to the Stop
to patient car

Put confirmed
Patient Service Coordinator

DC in
Bedboard

Hear sound of Review DC Page other Call RN to let Highlight Transcribe DC Place chart Record DC Write DC in Photo copy DC File DC Breakdow n Enter OBS
chart being put order and disciplines to him/her know patient's room order into Care back on rack inf o in Census Medical paperw ork paperw ork chart charges in to
in rack prescriptions complete pt about DC number on Manager for RN to co- Book Records log copy IDX
care w ith order assignment (note 11) sign (note 14) (note 15)
priority for DC sheet Write DC on
large w hite
board

Notify Primary Assist Primary Remove

RN about DC RN w ith DC if patient f rom
orders RN is too busy Care Manager
Charge Nurse

(Note 10)

Page other
disciplines to
complete pt
care w ith
priority for DC

Review DC Complete Contact home Compile Send

Home Health Coordinator

Does pt Yes paperw ork "home care care agencies paperw ork to paperw ork to
need home send to agency Stop
(pink sheet) assessment"
health care accepting (16)
for medical (Note 12)
needs agency

No

Stop

Yes Review DC Yes

Fax pink sheet Call company
Does pt paperw ork to infusion Does pt to set up
Case Manager

(pink sheet) need home Stop

need home center equipment
for medical equipment (17)
antibiotics delivery
needs (note 13)
No
No

Stop

Determine Get chart f rom Talk to family Contact SNF Copy chart Arrange Fax orders to Call SNF to
payor source rack
Does pt Yes about w hat about transportation SNF update about
Social Worker

need SW Stop
they w ant placement departure
services time/needs

No

Stop

Yes Expedite meds Yes Yes Counsel

Do es pt Do es pt Can pt affo rd
being patient on use
need inpt have prescriptio ns Stop
meds befo re processed by prescriptio ns of certain
DC inpt pharmacy to be filled medications

No No
No

Notify Social
Will patient Yes Worker for
qualify fo r assistance
CICP
w ith CICP
Pharmacist

registration

No

Yes Contact
Do es pt qualify
physician to
fo r o utpt
assistance recommend
pro gram cheaper
therapy

No

Refer pt to
outpt
pharmacy for
assistance

Receive page Go to patient's

Yes Take patient Take patient to
Yes Take pt to car Enter job
fro m Care Will pt be Do es pt Yes Is wait at
room off unit pharmacy completed in
M anager that pt need to go pharmacy
ready in 5 phone system
is ready fo r to less than 5
mins minutes
discharge pharmac y
Transporter

No No
Enter complete
code in phone Reschedule pt
Reschedule pt No
system pick up in
pick up in
system system

Receive page Go to patient Log into phone Find someone Clean room Log out in
w ith room room system ("in to remove (45-60 phone system
EVS

Stop
number progress") medical mintues) ("clean")
("dirty") supplies
 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
Worlds Greatest Manufacturer. McGraw-Hill: 2004.
OLeary 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?