In my last blog post, I introduced the concept of Lean Methodology for Healthcare and provided readers with the basic overview to its purpose, goals and basic principles. To quickly refresh your memories, the overall purpose and goal of Lean thinking, simply stated, is to eliminate unnecessary waste to drive value. In order to achieve this, a focused process improvement strategy needs to be in place. Lean’s 5 basic principles accomplish just that!
In this blog I would like to take a deeper dive into the 5 basic lean principles I previously introduced and explain how they achieve smooth process flows, doing only those activities that add value and eliminate activities that don’t1.
The 5 Basic Lean Principles*:
The Cardiff University, Purple Doodle (a Yahoo! Network Contributor), and the American Health Information Management Association (AHIMA), do an outstanding job of explaining and providing examples of these 5 key principles in Lean thinking:
1. Identify Customers and Specify Value – This is the critical starting point for lean thinking, as only a small fraction of the total time and effort in any organization actually adds value for the end customer2. Value can be defined only by the customer and is meaningful only when expressed in terms of a specific product or service, which meets the customer’s needs at a specific price at a specific time3. Though this definition seems simple, it is not so simple to implement because other interests, such as the immediate needs of the shareholder and the financial mindset of the senior managers, often take precedence over the day-to-day realities of specifying and creating value for the customers3. By clearly defining Value for a specific product or service from the end customer’s perspective, all the non-value activities – or waste – can be targeted for removal2. The two considerations that are important while attempting to define value are3:
- To define value in terms of the whole product/service otherwise different people will tend to define it in their own way to suit their own needs
- To define target cost in terms of the amount of resources and effort required to make a product/provide a service of a given specification if all the visible waste were removed
Healthcare example4: Patients routinely get stuck in processes that do not add value to their care. They wait 30 minutes to see their primary care physician, or they fill out a patient medical history form multiple times within the same medical encounter. Those processes were designed to add value to the healthcare professional, not the customer.
Once value is defined, it becomes the lens for examining every step in the “value stream.”
2. Identify and Map the Value Stream – The Value Stream is the entire set of activities across all parts of the organization involved in jointly delivering the product or service and represents the end-to-end process that delivers the value to the customer2. Once the organization understands what the customer wants the next step is to identify how the organization is delivering (or not) that to them2. This step typically exposes enormous amounts of waste. The value stream for a product or service has three categories of activities: (a) those that create value (b) those that do not create value but are necessary (c) those that create no value and are ‘waste’. It requires a new way of thinking to create a channel for the entire value stream, dredging away all the waste and requires transparency regarding all the steps taken to see if the other participants are behaving in accordance with the agreed principles3. Defining the Value Stream is based on the following two premises3:
- Activities that cannot be measured cannot be managed
- There is no need to benchmark against competition; compete against perfection by eliminating waste
Healthcare example4: A patient being examined by the physician adds clear value to the patient. The step of filling out a medical history form multiple times is a step that could be interpreted as adding no value but which is unavoidable due to current processing requirements. Finally, the step of waiting 30 minutes to see the physician adds no value and should be removed immediately.
3. Create Flow by Eliminating Waste – Typically when you first map the Value Stream you will find that only 5% of activities add value, this can rise to 45% in a service environment2. Eliminating this waste ensures that your product or service “flows” to the customer without any interruption, detour or waiting2. Flow is about redefining the work of functions, departments and firms so they make a positive contribution to value creation and speak to the real needs of employees at every point along the value stream so it is actually in their interest to make value flow3. Therefore, the focus has to be on the actual product or service and how to eliminate waste and interruptions and not on the jobs, careers, departments, firms or work practices3. There are “7 wastes” in Lean Methodology. These are activities identified and categorized as non-value adding events or processes that limit profitability in an organization. (Note, we will take a closer look at the 7 wastes in more detail in my next blog.)
Healthcare example4: The US healthcare system is built on batch and queue systems. A patient who feels sick calls his physician and makes an appointment. At the appointed date and time, he arrives at the provider’s office and waits to be seen. Upon examination, the doctor may recommend the patient see a specialist, have laboratory tests performed, and even begin taking a prescribed medication. Each step entails waiting for a service or product to be delivered.
4. Respond to Customer Pull – This principle is about understanding the customer demand on the service and then creating the process to respond to this demand2. Pull is the ability to design, schedule and offer exactly what the customer wants just when the customer wants it3. This is the move away from batch and queue style of organization where the processes are disconnected and aggregated, to an entire flow of value creating activities for specific products or services3.
Healthcare example4: During the transfer of a baby from a surgical suite to a neonatal intensive care unit (NICU), if the baby arrives at the NICU and the respirator and the respiratory therapist are not waiting for the patient, there is a problem. Pull works to ensure that the respirator, the respiratory therapist, and charge nurse are ready and waiting when the baby arrives in the NICU.
5. Pursue Perfection – Creating flow and pull starts with radically reorganizing individual process steps, but the gains become truly significant as the steps link together2. As this happens more and more layers of waste become transparent and the process continues towards the theoretical end point of perfection, where every asset and every action adds value for the end customer2. It is important to note that there is no real end to the process of reducing effort, time, space, cost and mistakes while offering a product or service3, as there is always remove for improving the present system.
5 Principles at work in Healthcare
As you can see from the examples above, Lean thinking can be adapted to the complex world of healthcare Mr. Steven Garnfinkel, in his article, “Making Healthcare Lean“, explains how Lean principles proved to be successful at one hospital that chose to improve performance on door-to-balloon time, or D2B, a measure for heart attack treatment. He describes the following5:
“Staff members from the emergency department and the cath lab at the hospital met to identify and eliminate points at which delays occurred. They found that one cause of long D2B time was that a technician had to travel from home to set up the cath lab during night shifts. D2B time decreased when ED nurses and technicians were trained to start the setup right after a patient was confirmed to have ST segment elevation myocardial infarction. Additionally, the cath lab staff received a checklist of exactly what the ED staff had completed prior to handoff of all patients. As a result of these changes, average D2B time dropped from 89 minutes to 77.”
In addition the hospital decreased the following5:
- Time from arrival at ED to initial clinical evaluation from 60 minutes to three minutes;
- Time to assign beds to ED patients from 45 minutes to 20 minutes;
- Time to file clinic charts by 70 minutes;
- Surgical procedure cards printed per week from 15,000 to 8,000;
- Physical steps in the general toileting process of post-acute patients by 35 percent;
- Denial of payment in ambulatory pediatric practice by 70 percent.
Lean thinking is all about doing more with less -less human effort, less equipment, less time and less space while coming closer and closer to providing customers with exactly what they want. It is about helping organizations and its leadership clearly specify value, to line up all the value-creating activities for a specific product or service along a value stream and to make value flow smoothly at the pull of the customer in pursuit of perfection6. Given the nature of our healthcare environment today, following these 5 principles of Lean thinking can prove to be an effective and significant methodology for improvement, something our healthcare industry so desperately needs.
*For the purpose of the healthcare industry, “customer” depending on the process can be a patient, provider or administrator and “product or service” is the delivery of care or services within a healthcare setting.
Stay tuned for my next blog in this series where I will describe the 7 deadly wastes of the Lean Methodology and how they apply to healthcare.
Resources for this blog post:
- http://www.bizmanualz.com/information/2005/07/14/lean-thinking-for-process-improvement.html
- http://cardiff.ac.uk/lean/principles/index.html
- http://voices.yahoo.com/lean-thinking-book-its-principles-2511623.html
- http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_043753.hcsp?dDocName=bok1_043753
- http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=4920002085
- http://www.lean.org/WhatsLean/Principles.cfm
