Lean tools and lean transformation process in health care

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1 ISSN , England, UK International Journal of Management Science and Engineering Management, 5(5): , Lean tools and lean transformation process in health care V. Cruz Machado 1, Ursula Leitner 2 1 UNIDEMI, Departement of Mechanical and Industrial Engineering, Faculty of Sciences and Technology, Universidade Nova de Lisboa, Caparica , Portugal 2 UNIDEMI, Department of Industrial Engineering, Vienna University of Technology, Vienna 1040, Austria (Received 20 January 2010, Revised 27 May 2010, Accepted 3 July 2010) Abstract. This paper describes 24 case studies concerning lean transformation in health care systems; the cases were analyzed on used lean tools and described lean transformation processes. All the mentioned lean transformation processes were analyzed regarding the common and most important steps. The universal standard process was then created by synthesizing them. Steps and content of this transformation process are proposed and explained. A final purpose of this paper is to discuss lean tools in health care systems and how a standard lean transformation process can be designed regarding best-practices. Keywords: health care systems, hospital management, lean tools, lean management 1 Introduction The health care sector in Western countries is facing more and more serious budget problems. Due to scientific achievements an increasing number of diseases can be treated, which, together with an increasingly older population demanding care, leads to growing consumptions and costs in health care (Tragardh and Lindberg, 2004 [18]). Since costs are increasingly faster than productivity and resources originating from government or insurance companies are stagnating or even decreasing, available funds fail more and more to meet the hospital s demand. In other words: Money is due to run out (Fillingham, 2007 [6]). Consequently, quality as well as patient and staff satisfaction are decreasing while waiting times and delays are increasing. Health care does not succeed in meeting patient needs any more (Heuvel et al., 2006 [8]). There are two ways to solve this problem: Pumping more money in health care which is a quick but expensive approach just fighting against symptoms of a sick system and only solving the problems for the short term or fixing the whole system in the long run by searching for the roots of the failing system and curing it at its sources. The second approach should be chosen. While some causes of the cost explosion like the over aging population or the increasing number of possible health cures cannot be changed, high potential for cost reduction is given in redesigning health care organization and working procedures (Tragardh and Lindberg, 2004 [18]). In general, health care is often described as badly managed. Care processes are often seen as poorly designed and characterised by unnecessary duplication of services, long waiting times and delays (Heuvel and et al., 2006 [8]). Thus, one prime solution for curing health care is managing the whole system in a complete new manner which should increase efficiency and productivity of work. Fortunately, such a management system doesn t have to be invented any more. It is already existing meeting perfectly our needs. It can simultaneously improve quality, morale and productivity (Fillingham, 2007 [6]). Its name is lean. 2 What is lean This research is funded by Fundação para a Ciência e Tecnologia (Project UNIDEMI). Correspondence to: address: [email protected]. Lean management can be described as a normative method or production philosophy originating from Japan (Tragardh and Lindberg, 2004 [18]). It derives from the Toyota Production System developed by Toyota in the 50ties of the last century. The idea was to stop depending on mass inspection to achieve quality and, instead, focus on improving the production process and building quality into the product in the first place (Miller, 2005 [15]). The production process should be rationalized, which means the elimination of waste (muda in Japanese) in any form, anytime, anywhere. The rationalization of producing should not only increase efficiency but also provide higher quality of the products. In other words: Using less to do more (Miller, 2005 [15]). Whereas higher quality and less effort is often seen as a trade-off in traditional management systems it is not a discrepancy in lean thinking (Laursen et al., 2003 [13]). The focus on internal quality, like fewer defects or less delay in the production process, as well as quality towards customers may lead to higher efficiency, productivity and customer satisfaction accompanying significant cost reduction. After introducing lean management in Toyota higher quality output at half the cost in half the time of tradi- International Society of Management Science And Engineering Management Published by World Academic Press, World Academic Union

2 384 V. Machado & U. Leitner: Lean tools and lean transformation process in health care tional manufacturing methods was achieved (Fillingham, 2007 [6]). One of the main points in lean philosophy is to do things right in the first time or if errors are appearing to fix them immediately in order to minimise the danger of reproducing them which demands higher responsibility and a strong commitment by the staff. It is important to see lean not only as new a management method but as a universal philosophy and a new part of company culture. To sum up, lean is about improving processes by eliminating waste. All organizations are composed of a series of processes intended to create value for the customer (Miller, 2005 [15]). Every process involves an amount of different steps which can be value-added or non-value-added (and so pure muda). Thus one core element in lean management is the distinction between those two types of steps whereas the dividing line is determined by the customer: Value-added is what the customer wants of the product or service and he/she is willing to pay for (Heuvel et al., 2006 [8]). So, after determining the value by distinguishing value-added steps from non-value-added steps, all the non-value-added steps have to be eliminated so that ultimately every step adds value to the process (Miller, 2005 [15]). Errors, duplication and delay are reduced positively influencing the whole production process and so the whole company performance. 2.1 The five key principles Lean thinking involves five lean principles which can be seen as more than mere principles; these also indicate an implementation path or procedure (Laursen et al., 2003 [13]): Define value desired by the customer. Identify the value stream for each product or service providing that value and challenge all the wasted steps in the processes (Ben-Tovim et al., 2007 [3]). Create flow: The product or service should flow continuously (no waiting and delay) often applying Just-In-Time policy, that aims reducing buffers between steps (Brandao, 2009 [4]). Establish pull: The flow should be based on the pull, the expressed needs, of the customer (Miller, 2005 [15]). Pursuit perfection like the continuous seeking to make improvements (also known as kaizen) and to eliminate waste (Laursen et al., 2003 [13]). 2.2 Muda In lean all is about eliminating waste, also known as the muda technique where all the steps of one process are classified in value-added or non-value-added ones whereas value is defined from the point-of-view of the customers. Thus, a holistic understanding for defining value is necessary. A step which seems to be value-added from one point of view, often of an employees view who doesn t want to see his/her work as useless and eliminate his/herself, may be interpreted as pure muda from a holistic point-of-view (Laursen et al., 2003 [13]). Furthermore the identification of muda can be facilitated by classifying waste in specific types. Seven areas have been defined by Toyota (Zidel, 2006 [21]; Fillingham, 2007 [6]). Examples adapted to health care are given in the following: Delay: waiting for diagnosis and treatment. Over processing: excessive paperwork, redundant processes. Inventory: unneeded stocks and supplies. Transportation: movement of patients and equipment. Motion: movement of staff and information. Over production: unnecessary tests, unused services. Defects: medication errors, infections. The power of lean is that it is a universal system. It can be applied to any form of work (Fillingham, 2007 [6]). Originating from car manufacturing (Toyota) lean was soon applied in other industries where it achieved remarkable results (Laursen et al., 2003 [13]). Thus, the successful translating of lean thinking to the hospital environment was only a matter of time. It was shown that the principles of lean can work in health care in much the same way as they do in other industries because it has to do with improving processes (Miller, 2005 [15]) and eliminating waste which can be found in almost every area. Lean helps to perform work in hospitals more efficiently and consequently reduce costs, which is the most important and urgent claim in today s health care. 3 The three lean approaches In a first approach lean can be seen as a philosophy with the goal of eliminating waste. This philosophy is not only used in car industries, its origin fields, but also in other areas like health care. Everywhere were waste is supposed to appear and efficiency is wanted to be increased lean can be a fine method to make things better, cheaper and faster. It s a universal philosophy and more and more fields are found for the application of lean. In the second approach lean is a system which offers a set of lean tools. The philosophy of lean sounds nice and logical. Principles are manifested that create a whole new way of management thinking. If you study lean philosophy you get eager to finally implement it. You say, Ok, I understand what we have to do, so just do it. But this is more difficult than it seems to be. Transforming a way of thinking into real deeds is not easy at all. In apparent response, most descriptions of lean management quickly move beyond the philosophical to an interrelated set of practises also called lean tools (Jimmerson et al., 2005 [9]). They can be seen as a series of methods that give direct instructions on how to apply lean thinking and consequently facilitate lean management in practise. More than 100 different tools are available, each with a specific focus (Laursen et al., 2003 [13]). Thus, depending on the kind of lean implementation, the tools that best meet the problem can be chosen of a large pool. Since lean tools seem to be part of the core aspects in the practical application of lean, they should be accounted for in more detail, which is done in the next chapter where their occurrence in literature is analyzed and the most current ones are introduced. But lean is not only a toolkit, a box with independent tools, where you can choose the one that fits best, which leads us to the third approach. Lean can be an instruction manual, as well. Besides the application of specific tools, an overall transformation plan is needed. It describes which the different steps of a whole lean transformation process are, in which order they are arranged, when lean tools are chosen, when they are applied and which other steps concerning preparation and post-processing are needed. Lean provides guidelines by a step-by-step program including lean tools. Many case studies of lean application in health care are documented in literature. Brandao de Souza s Paper Trends and approaches in lean healthcare (see Brandao, 2009 [4]) documents a number of them from 2000 onward. In this paper those were analyzed on occurring lean tools to provide a review which are actually used in real lean transformation process and give an idea which ones are the most useful ones. All the case studies were analyzed on IJMSEM for contribution: [email protected]

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(Bran- This should give an used lean 2006 tools: [21]). it was determined idea about which dao, tools 2009 are [4]). the most Although important the and consequently areas seemthe tomost differ useful. strongly Creating a value stream map is not as difficult as it seems. The case studies are classified in four from different eachcategories other, describing lean is more the area orof less application: applied manufacturing-like, the same Basically, all you have to do is to chose a patient and follow patient flow, organisational, way management and the and same support tools (Brandao, are used. 2009). This Although fact the reinforces areas seem to the his/her way during the process through the system. 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If you know the 0 VSM Time Visual 5S Standard Stop Process PDSA work in other units collaboration will be improved. Working conditions are understood better and it s easier to reach Map Fig. Figure 1 Occurrence 1: of oflean lean tools tools practical solutions (Tragardh and Lindberg, 2004 [18]). Em- Figure 1 shows Fig. the 1occurrence shows the of the occurrence most mentioned of the tools most in the mentioned 24 case studies. tools The value ployees stream can see for the first time all the steps a patient has map is the most in used the one 24 (eleven case studies. times). It The is followed valueequally stream by conducting map is the time most measurements to goand in a hospital s visit and recognise his/her part in the visual management used one (nine (eleven times). times). 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The All the tools Standardization that were mentioned (seven at least twice times). in the Stoping-the-line analyzed case studies are and listed Process The Map tools are follow all described them equally in the analyzed (four paper s times). manner Plan-Do-Study- which means a description from a patient s point of view (Bushell and Shelest, 2002 and explained most in important thing is that processes have to be observed the following. regarding operator s Act Cycles words (the is authors mentioned of the case three studies). times. This provides a practical approach [5]). since As all mentioned before, he/she is the key person in the tools are explained All regarding the tools their that direct were application mentioned in the case atstudies. least Every twiceauthor in the focuses analyzed tools, so case different studies definitions are listed were given. and explained The goal this in the paper following. is to take these they different have to be eliminated. on process. different All the steps should add value to him/her if not aspects of these The tools are all described in the analyzed paper s manner which means a description regarding operator s words (the authors of the case studies). This provides a practical approach since all tools are explained regarding their direct application in the case studies. Every author focuses on different aspects of these tools, so different definitions were given. The goal in this paper is to take these different approaches and put them together to one definition. It is furthermore providing answers to the following questions: How the author defines and explains the tools? How they are understood in practice? How the tools are used (which department, which health care process)? 4.1 Value stream map The most mentioned tool was by far the Value Stream Map. According to Koning et al. (2006) [12] the value stream map is the primary analytical tool in a lean transformation. So what is a value stream map exactly and where it can be applied? The value stream map is an extended process flowchart with information about speed, continuity of flow and work in progress that highlights non-valueadded steps and bottlenecks (Koning et al., 2006 [12]). It helps to understand the flow of the product/customer. The value stream map can not only be used for describing the current state but also for the future state. It describes how the process should be changed to move towards perfection (Miller, 2005 [15]); which means that non-value added steps are eliminated or at least reduced if elimination is not completely possible. Some value added steps can be merged to one big one and as a result more efficiency can be reached. The future state value stream map includes like the current state map the duration of all the single steps. Value stream maps display both, the elapsed process time and the actual required work time. Whereas the elapsed process time (sum of duration of all steps) should be reduced the actual required work time (sum of duration of all value added steps also) remains the same as the actual work steps are all value added steps and their needed time cannot be decreased because there is no waste to eliminate (Miller, 2005 [15]). Furthermore, it is important that the value stream map is drawn by an internal person, like a doctor, a nurse or a manager. If they see the whole process with their own eyes and document it with their own hands it is much easier to understand and then to improve it. A multidisciplinary (Kim et al., 2007 [11]; Fillingham, 2007 [6]) team is needed which is certainly trained in lean. A patient can be part IJMSEM for subscription: [email protected]

4 386 V. Machado & U. Leitner: Lean tools and lean transformation process in health care of it as well. Which is important is to see the process with different eyes so that every side can contribute to the improvement and profit from the observation. As mentioned before value stream maps are often applied in lean transformation processes as in Miller (2005) [15] who gives the example of the current and future state value stream map of an insurance claim process. Fig. 2 shows the current value stream map indicating nine steps and their duration and asking if each step is value adding or not. Whereas the elapsed process time is about 28 days the actual required work time is only 19 minutes. Thus there are large areas of waste that should be eliminated. Fig. 3 shows the future state value stream map. It indicates how the process should be after lean improvement. The formerly nine steps were merged to three. Most of the wasted time is eliminated so that the elapsed process time is now only 8.3 hours which is an incredible improvement compared to the formerly 28 days. Further application areas are given in the following: (1) In Kim et al. (2007) [11] a current and future state value stream maps for the treatment of bone and brain metastasis is developed. (2) In Fillingham (2007) [6] the flow of patients with fractured hips are mapped from arrival through radiology, the wards and so on. (3) Laursen et al. (2003) maps a by-pass operation procedure. (4) In Towne (2006) [17] material flow is focused: The whole supply chain from purchase order to accounts payable is drawn in the value stream map. (5) In Jimmerson et al. (2005) [9] information flow in form of pathology reports is described in current and future state value stream maps. 4.2 Conducting time measurements Several time conducting measurements are mentioned. They are useful tools in a lean transformation process often linked to the value stream map where the duration of each step in the process and the whole process is measured (Laursen et al., 2003 [13]; Miller, 2005 [15]; Kim et al., 2007 [11]) but also process maps may involve time studies (Workman-Germann and Haag, 2007 [20]). It helps to understand the importance and influence of single steps in the whole process and points out fields of improvement. Process efficiency can be calculated by setting the relation of valueadded time and non value added time. Furthermore, the success of an implemented lean transformation can be provided by comparing time before and after implementation (Persoon et al., 2006 [16]; chemistry tests time studies in a benchmarking process). In the respective literature several time terms are used sometimes having the same definition but different names. In the following all the mentioned terms are discussed. Lead time tells us how long any item of work will take to be completed. According to Little s Law the lead time equals the amount of work in process divided by the average completion rate (Heuvel et al., 2006 [8]). It is the time to process one patient through the entire value stream (Zidel, 2006 [21]). The reduction of lead time is postulated to eliminate waste and to achieve higher efficiencies in patient treatments as in the emergency room (Heuvel et al., 2006 [8]) or by-pass operation procedures (Laursen et al., 2003 [13]). This can be achieved either by reducing the amount of work in process or by increasing the average completion rate. Cycle time is the amount of time necessary to complete one cycle of a process or a step (sometimes also called operation, Zidel, 2006 [21]) that can be value-added or non-value added. So you differentiate between process cycle time for the whole process and operation cycle time for one step. The definition of process cycle time seems to be the same as for lead time but in fact it is not the same at all. Lead time is calculated by two different variables (amount of work in process, average completion rate) whereas cycle time is measured directly by observing all the single steps of one process that is needed for example when doing a value stream map. The process cycle time can also be called total lead time (Kim et al., 2007 [11]; Laursen et al., 2003 [13]) or elapsed process time (Miller, 2005 [15]) describing the total elapsed time associated with completing a process. Whereas process time (Kim et al., 2007 [11]) or total processing time (Laursen et al., 2003 [13]) defines the actual time it takes to complete a process and consequently the actual required work time (sum of operation cycle time of all value added steps). Takt time is calculated by dividing available time by the number of the patients describing the pace at which the medical service must be provided in order to meet the patient s demand (Zidel, 2006 [21]). In other words it is the amount of time that is available to carry out a step or process. It is critically important that the cycle time of one step or process is shorter than (or equal to) its takt time if not it will lead to delay and waiting times, waste that must be eliminated. For example in Bahensky et al. (2005) [1] the comparison of takt time and cycle time determines the requested duration of processing a computerized tomography to meet the demand of the patient and so provide workflow. Changeover time (Zidel, 2006 [21]) is the time required to change over from one patient to the next. It begins when the current process of providing a service is finished and ends when the next service begins. So it is the time between services when nothing is happening. Reducing changeover time can improve flow and efficiency. Furthermore, two efficiency measuring variables are mentioned. Kim et al. (2007) [11] defines the process cycle efficiency which is process time divided by total lead time and so giving a measure of what percentage of time is spent in value added steps. Zidel (2006) [21] provides the process efficiency percentage (PEP) which is the ratio of value-addedtime and lead time. 4.3 Visual management Visual management is closely linked to the 5S method and helps to arrange a workplace in a well ordered and organized way for example in Manos et al. (2006) [14]. Signs, lines, labels, lists and colour coding eliminate guessing, searching and hoarding for information and material. Visual management may provide flow by designing them in a way so that employees can simply go-and-see what is happening and exactly the next problem they should be solving without disturbing other staff from their value added tasks (Fillingham, 2007 [6]). Furthermore, it can help to point out whether or not the process was operating correctly and what kinds of quality problems and errors were occurring (Fillingham, 2007 [6]). It can support efficient time management for example in operation theatres as described by Koning et al. (2006) [12]: At the weekly staff meeting a specially designed graph was reviewed showing the operation theatres start times for the previous week. The feedback from this control system was used to continually monitor the operation theatres starting IJMSEM for contribution: [email protected]

5 International Journal of Management Science and Engineering Management, 5(5): , Receiving: Open and array docs Compile Folder with Docs Verify Claim Calculate Amount and address Print, Stuff and Mail Check Valuable? Valuable? Valuable? Valuable? Valuable? Valuable? Valuable? Valuable? Valuable? 9 7 days 7 days 7 days 7 days 28 days 1 2 min 5 min 10 min 1 min 1 min 19 min Fig. 2 Current state value stream map for insurance claim processing (see Miller, 2005 [15]) Receiving: Open and array docs Three Person Team: Doc Verification, Claim Verification and Check Authorization Print, Stuff and Mail Check Valuable? Valuable? Valuable? Valuable? Valuable? 5 4 hours 4 hours 8.3 hours 1 2 min 16 min 1 min 19 min Fig. 3 Future state value stream map for insurance claim processing (see Miller, 2005 [15]) times and provide input on how to improve processes even further. The simple posting of graphic images can remind staff of doing standard work (Ballé and Régnier, 2007 [2]) or communicate to employees important information like in Miller (2005) [15] where the whole culture changing plans were provided by images throughout the organization. The best known visual tool is called kanban which means sign board. It visually displays what s needed to keep a process moving informing when to make, move or get materials from the external supplier. A kanban may signal for example that an item requires replenishing (Zidel, 2006 [21]). The signal can take any form. It may be a card, an alarm a light or simply a square on the floor or a bin which shows that something is missing if it s empty. Thus it is the perfect tool for applying 5S, establishing jidoka (react at first defect) and providing JIT (Just-In-Time). A further visual tool is andon which means light. It is most commonly a light or an audible signal, but may be any signal used to bring attention to a particular situation (Zidel, 2006 [21]) like occurring of errors and safety lacks S Another often mentioned tool is 5S. This tool is best described as a place for everything and everything in its place. It is a specific method for organising workspace. The goal of 5S is to organize the work area in the way, that needed objects are found easily and quickly so that work can be done more efficiently by creating smooth workflow. 5S refers to the five words Japanese words seri-seitonseiso-seiketsu-shitsuki. In English these words mean organize-orderliness-cleanliness-standardize-discipline. In order to maintain the 5S acronym, five related English words beginning with the letter S have been adopted: sortstraighten-scrub-standardize and sustain (Zidel, 2006 [21]). Every word describes a step in the 5S work space transformation process. The focal point of the first step Sort is the elimination of all the unneeded items from the work area. There is no space for useless things so storage of not needed items is absolutely unnecessary. In the second step Straighten the remained items are organized. They should be easy to find, to use and to return. Frequently used items should be placed closer to someone s workplace and easier to attain than rarely used items. A better overview of storage areas can simply be achieved by implementing a labelling system. Lists of all the supply items in alphabetical order can be provided which detail the exact location of all the items (Manos et al., 2006 [14]). Using wardrobes with glass doors instead of intransparent doors facilitates and accelerates the search. Often mentioned with this step is Just-In-Time (JIT) which means here that items are delivered just before they run out or services are provided when they are needed. JIT s main principle is the reduction of buffers (like storage areas, waiting times) between steps. Its application can ensure that medical service is available immediately in the case of emergency. It is a powerful solution for the structural lack of storage space as well. In many cases weekly deliveries of supply items are the norm, which obviously floods storage room. Daily deliveries can reduce this problem. On the other hand risk of supply failure increases as less stock is provided. The optimal supply provision can be very difficult the more so as health care demand is highly unpredictable. Weber (2006) [19] suggests to meet this peoblem by the use of heijunka. A proceeding which figures out how to average uneven customer demand over time so as to create a predictable and level process flow (Weber, 2006 [19]) which was succesfully launched in Ballé and Régnier (2007) [2] during the implementation of 5S in storage areas. It was achieved to react immediately to an emerging lack of supply and understand daily consumption of each product so that stock levels could be set accordingly. The nursing managers started to recalculate all the stock levels on a quarterly basis to allow for the constant change in patient population, and hence the varying level of needs for various products. Furthermore jidoka another lean principle which which means react at first defect was applied. It ensures that corrective actions are set at the very first risk of missing products (Ballé and Régnier, 2007 [2]). The Supermarket policy also known IJMSEM for subscription: [email protected]

6 388 V. Machado & U. Leitner: Lean tools and lean transformation process in health care as the FIFO (first-in-first-out) principle is linked to this step as well as and was mentioned in Ballé and Régnier (2007) [2]. Newest deliveries are placed at the back of the queue (for example in a wardrobe or shelve) like in the supermarket so that older products are likely to be used first. This method reduces the risk that the items become outof-date accordingly money can be saved by reducing waste and quality can be improved by reducing the probability of using bad products. The third step Scrub describes the need of a clean environment. Everything should be well cleaned and bright to provide a more comfortable work space and subsequently increase efficiency and quality. The fourth step Standardize helps to maintain the gains achieved by the implementation of the first three S s (Zidel, 2006 [21]). Everyone is responsible for maintaining the gains. Accordingly, communication is critical during this phase. How can employees do what they are supposed to do if they don t know what is to do? Staff must be instructed to this new kind of system and educated how to implement, use and most importantly maintain it. The fifth step Sustain is about developing a habit. According to studies it takes three weeks to form a habit (Zidel, 2006 [21]). As soon as 5S is implemented discipline is needed to preserve it. This step can be seen as the most important but also the most difficult one. The first four steps can be done easily in a very small amount of time compared to the last one. There is a difference between just sorting, straightening and scrubbing once to being aware of the standard to really live this method. 5S is not just one big clean up. It is an enduring system for which preserving discipline is needed. Furthermore, this step is the responsibility of management because it is best taught by example. 5S is often applied in storerooms (Manos et al., 2006 [14]; Ballé and Régnier, 2007 [2]) but basically it can be used in any other work areas where objects are placed and used namely: Sterile rooms (Towne, 2006 [17]). Trauma stabilization areas (Fillingham, 2007 [6]). Pharmacy departments (Zidel, 2006 [21]). Manos et al. (2006) [14] describes the implementation of 5S in staff break rooms. To choose an area that was used by everyone should encourage the lean efforts throughout the organization. In addition to providing a place for staff members the rooms were also used for work related meetings and conferences. Reference materials were stored there as well. Work related activities should not be placed in break rooms so another area was located for that. The reference material was removed. After rearranging the room it could be used as it should. A place for employees to enjoy time away from their tasks (Manos et al [14]). Whereas usually the 5S method is described as a system with 5 steps (like the name assumes) David Fillingham s Paper Can lean save lives? (2007) claims the 6S method providing six steps. The first five steps remain the same, the news sixth step is called Safety which means the continuously check for hazards and defects. 4.5 Standardization The Standardization of work is a key tool in lean management. It helps to improve the ability to provide care. Without standardization, there is likely to be great variability and complexity in how work is done, what leads to rework and defects and thus reduces the safety and the quality of care provided (Kim et al., 2007 [11]). To establish standard work lists of every step in every process on the basis of best practice have to be built. These can be done by the employees themselves because in general they share a good idea of what they were supposed to do theoretically. In real work situations it can happen that staff tends to skip some steps for a variety of reasons; because of a lack of time, of not considering a step as necessary or just because the step simply slipped their mind (Ballé and Régnier, 2007 [2]). When standard work is finally defined guidelines and checklists are worked out capturing the current best way of performing. From now on work must be done according to these rigid scripts. Here the difficulties of establishing standard work arise. Defining standard work is not that hard, maintaining it causes problems. The trick is not just to identify it but to embed it, so that it is carried out consistently on a daily basis (Fillingham, 2007 [6]). Supporting the new standard working into staff habits can be done for example by visual management. Guidelines and checklist should be made as visual as possible and make it easy to be reminded of and difficult to deviate from the standard (Zidel, 2006 [21]). It should be made sure that everyone is familiar with and involved in the standardization process. In the end it is critically important that not only the defined standard work is done on a daily basis it should also be open for kaizen (continuous improvement). The defined guidelines and checklist should be continuously improved and immediately modified if the plotline, not the actor, proves to be the source of a problem (Weber, 2006 [19]) and so ensuring quality, safety and efficiency in the long run. In literature you can find several case studies of standardization in different kinds of processes showing the universality of this tool. (1) Ballé and Régnier (2007) [2] describes the implementation of standardized nursing practices: After a first checklist on basic patient care was created by nurses and ward managers, actual care in practice was observed and compared with the ideal list. In real life the nurses tended to skip many of the steps. Sometimes because it simply slipped their minds, sometimes because they were facing specific difficulties. After those issues were discussed and problems identified were reduced the final actual nursing standard for basic care could be developed. Checklists for more technical care, such as bandages, catheter insertion and so on followed. These documents are now used to check how agency staff works with patients with the effect that over the first two years the rate of incidents per patient halved (Ballé and Régnier, 2007 [2]). (2) In Kim et al. (2007) [11] case study the way information was requested and collected was standardized in the palliative radiation therapy process for patients referred for bone and brain metastases. All the necessary information needed to be available early in the process with a high degree of accuracy to improve quality and efficiency. (3) Weber (2006) [19] provides standardized work sequencing for physicians in form of a step-by-step pattern of tasks (see Tab. 1); each doctor is supposed to execute immediately upon emerging from a patient visit; a procedure which leads to greater efficiency and productivity in physician s work: Patients can now get same-day appointments, the volume of calls has been reduced by a third while visits are up 10 percent. 4.6 Stopping-the-line Patient safety or defect alert systems are fundamental elements of lean management. Their principle, called IJMSEM for contribution: [email protected]

7 International Journal of Management Science and Engineering Management, 5(5): , Table 1 Example of a step-by-step pattern (Weber, 2006 [19]) (1) Fill out a charge slip for the visit (2) Document the visit (3) Respond to at least one routine message from the medical assistants who answer the clinic s telephones (4) Answer at least one urgent message (5) Read and reply to at least one piece of hard-copy mail (6) Fill out at least one result report (7) See the next patient stopping-the-line, originates from the gemba (shop floor) of Toyota. There, every worker has the power and the obligation to stop the assembly line when a defect or error is identified or even suspected (Miller, 2005 [15]) so that a defective part will not go on from one work station to the next. Supervisors come running not to admonish the worker for stopping the production, but to help to fix the problem (Kaplan and Patterson, 2008 [10]) together with the line workers often preventing an error from becoming integrated in the final product. The theory of stopping-the-line and so of every patient safety/defect alert system is that mistakes are inevitable, but reversible. Defects are mistakes that were not fixed at the origin, passed on to another process or not noticed soon enough and are now relatively permanent. If mistakes are fixed early enough in the process, the product will have zero defects and so perfection is achieved. Mistakes are at least harmful end easiest to fix the closer you get to them concerning the time and place they occur (Miller, 2005 [15]). Since lean is a universal philosophy with universal tools, the stopping-the-line concept can also be applied in health care. Every employee can, and indeed must stop the line/care process if they feel something is not right (Miller, 2005 [15]). Staff signals for example by whistles (Weber, 2006 [19]), phone or (Miller, 2005 [15]; Furman, 2005 [7]; Kaplan and Patterson, 2008 [10]) if a condition that could lead to an error is noticed or complete safety is not assured any more. Furman (2005) [7] describes the implementation of a patient safety alert system in a hospital and postulates following points: Every staff is an inspector. Inspect, stop, and fix at the source if possible. Any and all staff can stop the line. When you can t fix on the spot STOP. If staff signals a problem, relevant executives and physician leaders are committed to respond immediately which means 24/7 drop-and run philosophy to assess the situation. The goal is to evaluate and fix immediately or if this is not possible doing a root-cause analysis (5 why s) and restart once the problem has been resolved. After the implementation of this system, the number of reports increased significantly and is wished to grow further. The hospital sets an ideal number of how many problems should be reported in a year in order to provide kaizen. Important is the fact that this approach happens on the gemba which means that executives and physician leaders go to were the process has been stopped rather than discuss in a boardroom or committee (Furman, 2005 [7]). A feature that is also noticed by Kaplan and Patterson (2008) [10]: The stopping-the-line system distributes the powerful message among staff that leadership cares about safety. Now they spend some time working with staff to resolve problems and so the great benefit of this system is that clinical and non-clinical executives gain a better understanding of what staff deals with. Furthermore, a patient safety/defect system asks all employees to be a patient safety inspector every day which implies a culture shift for staff. Nurses, for example, can report concerns, have them responded to and evaluated. In the old hierarchical culture, those may not have been reported. All in all, the stopping-the-line principle is one of the core pieces of lean management. It pursues the goal of zero defects, of perfection and is so far a great method for achieving it. Applying a patient safety/defect alert system increases safety, quality, staff satisfaction and efficiency. 4.7 Process map Similar to the value stream map is the process map. A process is the end-to-end sequence of steps required to transform a raw material to a finished product. So process mapping is the name given to the creation of an end-to-end flow diagram (Ben-Tovim et al., 2007 [3]). It visually depicts all the steps of a whole process by using standardized symbols and often includes time descriptions. While value stream maps are often take a broader and wider view, process maps can be very detailed describing processes at a micro level. In other words, whereas the value stream map is best used to identify opportunities the process map is best used to identify specific waste and improvements. It can be applied to every process in health care as listed in the following. Chemistry tests in a laboratory (Persoon et al., 2006 [16]). Patient flow (Ben-Tovim et al., 2007 [3]). Parallel processes as in Workman-Germann and Haag (2007) [20] who describes patient flow parallel to a radiology process. The focus is to go to the workplace ( gemb in Japanese), understand how work is done and describe it by drawing a process map. This map helps to reveal the roots that cause delay and other impediments to flow. As in doing a value stream map a multidisciplinary group is supposed to work it out. 4.8 Plan-do-study-act Often accompanying value stream maps or process maps are Plan-Do-Study-Act (PDSA) cycles (Miller, 2005 [15]; Manos et al., 2006 [14]; Ben-Tovim et al., 2007 [3]). Implementing and sustaining the future state of a process that is for example described by a value stream/process map involves PDSA cycles in which small changes are carried out, the results then assessed and analyzed and adjustments made. This method follows the principle of kaizen which means continuous improvement. There is always room for further improvements, the goal is perfection and if you stop to improve, it can never be reached. IJMSEM for subscription: [email protected]

8 390 V. Machado & U. Leitner: Lean tools and lean transformation process in health care In trying to create a perfect process small tests of changes should be designed ( Plan ) which are implemented on a small scale ( Do ). The performance compared with the current state is measured and reflections on how it could be better follow ( Study ). Finally the necessary changes to adjust the process are introduced on a bigger scale ( Act ). Furthermore, the process is determined on stability and sustainability. This method can be used iteratively so that continuous improvement is given and a stable and sustain process is provided. 4.9 Batch size reduction, one piece flow and cellular production 4.11 Spaghetti map A Spaghetti map can show the movement of one object, service, employee or patient through the entire process. It can simply be drawn on a floor plan by following the item or person of movement, as in Bahensky et al. (2005) [1] a radiology technician. The generated map points out the distance and the way you have to cover for completing a process. Movement should be kept low in potential areas of waste. By redesigning the work space in, for instance, a 5S manner, movement can be reduced, waste eliminated, efficiency increased and the whole process improved whys This tool is a question-asking method and the most common approach to investigate the root cause of a particular problem through a deep understanding of the current work process (Jimmerson et al., 2005 [9]). If the cause of a problem is understood it can be solved more easily. In the beginning, the problem is postulated and the cause is asked (first why). If the first answer is not sufficient for solving the problem and only revealing a linked problem, the cause of this linked problem is called into question (second why). The questioning is continued until the root cause is found and so the original problem can finally be solved. The name of the method does not necessarily means that you have to ask questions five times in a series to get to the root. Sometimes more, sometimes less iteration is necessary. It is important not to get lost in too many iterations and to still be connected to the original problem as well as not to ask too few questions stopping at symptoms and not going on to the real root cause P Batching of items such as laboratory tests, computer 3P means Production Preparation Process and focuses on the design of new processes and workspace records or of patients is not desired at all. At first, the batch size reduction may not seem plausible, but while batching (Miller, 2005 [15]). Normally it involves a series of multidisciplinary meetings several days a week within a short time may be efficient for a single step, it is not efficient for the whole process. While waiting to batch work, flow is not period to propose and test options for redesigning (Weber, given, objects or patients sit and wait while following steps 2006 [19]). cannot be served with input just in time (Manos et al., 2006 [14]). In lean all is about reducing waste, so anytime you set 5 Lean transformation process something down or have a patient wait, system efficiency is If you want to do a lean transformation, the most essential thing you should have is a good plan how to do it. reduced which costs your organization more money. Thus, one of the main lean principles is to have continuous flow. It makes no sense to apply tools to single steps of a process. First, it is important to see the complete care process This demands to complete work as it arose rather than treating it in batches (Ben-Tovim et al., 2007 [3]) which as a whole rather than a series of disconnected steps. The leads to another lean principle called one piece flow, a danger of point optimising is given, focusing only on the method in which all the activities that constitute a step of improvement of single steps and ignoring the impact that a process are performed on each object/patient undergoing P changes to a step may have on the steps on either side (Benthe step before the work is begun on the next object/patient 3P means Production Preparation Process and focuses on the design of new processes and workspace Tovim et al., 2007 [3]). Second, the use of tools should be (Persoon et al., 2006 [16]). (Miller, 2005). Normally it involves a series of multidisciplinary meetings several days a week within a Cellular production is supportive to this principle. short Itime period embedded to propose inand antest overall options for lean redesigning transformation (Weber, 2006). process, which describes the different steps of a whole lean transforma- refers to the physical linking of staff and equipment 5. so Lean Transformation process, in which Process order the single transformation steps the next step of a process gets the input from the previous If you want are to do arranged, a lean transformation, when the lean most tools essential are thing chosen, you should when have is they a good plan arehow to do step just in time (Manos et al., 2006 [14]), without accumulating work in between and having work stations tocare wait it. It makes applied no sense to and apply which tools to other single steps of a concerning process. First, it preparation is important to see and the complete process post-processing as a whole rather than are a series needed. of disconnected Since there steps. The is no danger one-and-only of point optimising is or in other words without creating batches. given, focusing process only on provided the improvement and processes of single steps inand literature ignoring the differ impact from that changes each to a step 4.10 Percent loading chart and line balancing may have on other steps the on goal either side was(ben-tovim, to identify 2007). asecond, standard the use process of tools should for lean be embedded in an overall lean process, which describes the different steps of a whole lean transformation transformation. The given transformation processes were In a percent loading chart, takt time and cycle timeprocess, can in which order the single transformation steps are arranged, when lean tools are chosen, when analyzed regarding the common and most important steps easily be compared and so areas of waste can be identified they are applied and which other steps concerning preparation and post-processing are needed. Since that were eventually synthesized to one universal standard and opportunities of creating better flow by redistributing work (also known as line balancing) pointed out. Once there no one-and-only process provided and processes in literature differ from each other the goal was process involving four steps that are indicated in Fig. 4 and to identify a standard process for lean transformation. The given transformation processes were analyzed regarding the described common and in the most following. important steps that were eventually synthesized to one universal more, the focus on the patient is shown. His/her pull sets standard process involving four steps that are indicated in Figure 5 and described in the following. the pace not the employee s ability to push it (Weber, 2006 [19]). IJMSEM for contribution: [email protected] Understanding the current state 1 Defining the future state 2 Implementing Lean 3 SUSTAIN 4 Figure 5: Four phases of standard lean transformation process Fig. 4 Four phases of standard lean transformation process 5.1. First step: Understanding the current state First, according to one of the five lean principles the value from the customer s point of view has to be 5.1 First step: understanding the current state defined. Value should be added to the customer during a process. The total health First, care according hospitals to involves one many of the different, five lean often principles dependent processes. the value If you want to do a lean transformation from the customer s it seems be impossible point of to view handle all has the to occurring be defined. processes Value at the same time, thus, a step-by-step shouldapproach be added is needed. to the First transformation customer during may be focused a process. on the most urgent processes like those that show the biggest inefficiency or cause the highest costs (Laursen, 2003). Transformation The total health care in hospitals involves many different, may be started at the key processes as well. Key processes are those that support core services, like an office visit, an inpatient oftenstay dependent or a visit to the processes. emergency department. If you want (cf. Miller, to 2005) do aafter lean dealing with those kinds transformation of processes, all the other it seems ones can to be done be impossible step by step. to handle all the Besides occurring the value stream processes map and its atincluded the same cycle time studies,, thus, some aother step-by-step key data, describing the current state approach like costs, failure is needed. rate, lead First time, transformation efficiency measures and may patient be focused satisfaction on may also be determined the regarding most a benchmarking urgent processes after like lean those transformation that show indicating the its success. biggest It is important to treat the hospital as one unity with a number of dependent processes. If you do lean transformation in one process it has to be considered that changing that process can influence other processes, as well, but not necessarily in a good manner. Doing one process more efficiently may for example force another dependent process to create more output which is perhaps not possible because of a

9 International Journal of Management Science and Engineering Management, 5(5): , inefficiency or cause the highest costs (Laursen et al., 2003 [13]). Transformation may be started at the key processes as well. Key processes are those that support core services, like an office visit, an inpatient stay or a visit to the emergency department (Miller, 2005 [15]). After dealing with those kinds of processes, all the other ones can be done step by step. Besides the value stream map and its included cycle time studies, some other key data, describing the current state like costs, failure rate, lead time, efficiency measures and patient satisfaction may also be determined regarding a benchmarking process after lean transformation indicating its success. It is important to treat the hospital as one unity with a number of dependent processes. If you do lean transformation in one process it has to be considered that changing that process can influence other processes, as well, but not necessarily in a good manner. Doing one process more efficiently may for example force another dependent process to create more output which is perhaps not possible because of a lack of resources. Thus, the improvement of one process can easily shift problems to another connected process. This phenomenon, also known as pillowcase syndrome (Ballé and Régnier, 2007 [2]), should be avoided by always keeping in mind the relation and the connection points between single processes. After identifying the value and the value providing processes it should be focused on how the value is spread. This can easily be done by applying the most important lean tool: the value stream map. It describes all the different steps involving a process and points out when and how value is added. The value stream map should be created by a multidisciplinary team of people who are closest to work (Jimmerson et al., 2005 [9]), like staff, physicians, executives and patients. Sometimes it can be useful to define some specific goals which should be achieved after the whole lean transformation is performed, like reducing lead time (Laursen et al., 2003 [13]; Heuvel et al., 2006 [8]) or meeting the future demand the hospital is faced (Laursen et al., 2003 [13]). 5.2 Second step: defining the future state After drawing the current state, value stream map areas of waste can be easily identified by asking if each step is a value-added or non-value-added one. Having the seven wastes (delay, over processing, inventory, transportation, motion, over production, defects) in your mind can support the identification by making the non-value-added steps obvious. The goal is now to eliminate or at least reduce the nonvalue-added steps of the process; a plan which may cause troubles. It is easy to see the problem areas of a process because they are clearly highlighted in the value stream map by classifying the steps in value-added and non-valueadded ones. It can be hard to solve them. At this point tools like the root cause analysis (Jimmerson et al., 2005 [9]) can help. After having understood the problems they can be solved more easily following the lean principles and the rigorous tools. The future state value stream map can now be drawn by asking how the process should be changed to move towards perfection (Miller, 2005 [15]). The map is the target condition of how the process should be after the lean transformation process. Since kaizen (continuous improvement) is persecuted the actual future state map will become the next current state map for the next round of improvements (Jimmerson et al., 2005 [9]). Furthermore, an improvement plan, a detailed work plan for implementing the future state value stream map, may be developed including which tools (standardizing, 5S, visual management) should be used and which lean principles (flow, pull, perfection) should be kept in mind for the redesign process. 5.3 Third step: implementing lean The next step is the actual implementation of lean targeting the future state vision by modifying the existing process based on the improvement opportunities that fall out of the current state value stream map (Ben-Tovim et al., 2007 [3]). The formerly created improvement plan is not only plan anymore it has to be set into action. It is time that the future state value stream map is implemented supported by lean principles and tools. Change cannot happen overnight. It is a long lasting process. The new system may be built up in several rounds of testing and redesigning. Good communication between the redesign team and normal staff is crucial. It is good to inform every employee about the implemented process changes so that he/she is able to work by these new standards and so provide improvement but it is better to really involve the whole staff in the improvement process. During the implementing period daily meetings between the redesign team and staff can help to identify and solve occurring problems. Comments are used to develop best practice (Persoon et al., 2006 [16]). In this phase methods like Plan-Do-Study-Act cycles (Miller, 2005 [15]; Ben-Tovim et al., 2007 [3]) or 3Ps (Production Preparation Process; Miller, 2005 [15]; Weber, 2006 [19]) are supposed to be applied providing kaizen. The success of lean implementation should be continuously measured (in values like patient satisfaction, failure rate, cycle time, lead time) and compared to expected improvements and formerly set goals pointing out the quality of already implemented activities of improvement and the need of further redesign rounds. Compared to the current state key data that were determined in the first phase can deal as a good indicator of the overall success of lean transformation. Furthermore, it is critically important for the success of a lean implementation to have a strong commitment to the change by the hospital managers. They should pose as a role model in lean thinking and doing and support the implementation of the transformation. However, problem solvers are still the redesign team and employees themselves. Lean thinking requires managers to ensure that a decision gets made, rather than make every decision (Ben-Tovim and et al., 2007 [3]). 5.4 Fourth step: sustain After implementation is made and the targets that were set in the first step are achieved, people often consider lean transformation as done but in fact it is not done at all. The really hard work begins right now. It has to be ensured that the achieved improvements sustain. If this goal is not persecuted processes may return to the state before lean transformation. Staff intends to forget new working policies because it is easier to return to old habits. So change has to be made sustainable (Ben-Tovim et al., 2007 [3]). Therefore a strong commitment towards lean standards of managers and employees is needed. They have to remind and be reminded of lean all the time, everywhere. Once more the importance of kaizen has to be pointed out. If the awareness of continuous improvement is not given you will be pinned in the status-quo what can be seen as regression. Lean transformation never ends. There IJMSEM for subscription: [email protected]

10 392 V. Machado & U. Leitner: Lean tools and lean transformation process in health care always occur things that have to be improved and waste that has to be eliminated. Staff and managers should be aware of providing kaizen always looking for waste areas, implementing improvement and so persecuting perfection and sustainability in the long run. 6 Conclusions As literature shows, lean tools embedded in lean transformation processes are a powerful way to make work in health care more efficient and consequently save money which is one of the top targets in today s health care sector. Cutting costs is often seen as a trade-off to quality but not in lean management. The implementation of lean can decrease costs and increase quality at the same time. Thus lean management is supposed to be a high-class method for improving the whole health care sector. A number of lean tools gives the opportunity to meet occurring problems adequately by choosing the best fitting one. The paper introduces the most used tools and hence provides help in deciding which would be the most useful ones. Furthermore, different lean transformation processes were analyzed regarding the common and most important steps. One universal standard process was created by synthesizing them. This standard process gives the idea of how tools should be applied and lean be implemented in the most successful way. References [1] Bahensky, J., Roe, J., and Bolton, R. (2005). Lean sigma will it work for healthcare? Journal of Healthcare Information Management, 19(1): [2] Ballé, M. and Régnier, A. (2007). Lean as a learning system in a hospital ward. Leadership in Health Services, 20(1): [3] Ben-Tovim, D., Bassham, J., and et al. (2007). Lean thinking across a hospital: redesigning care at the Flinders Medical Centre. Australian Health Review, 31(1): [4] Brandao, L. (2009). Trends and approaches in lean healthcare. Leadership in Health Services, 22(2): [5] Bushell, S. and Shelest, B. (2000). Discovering lean thinking at progressive healthcare. The Journal for Quality and Participation, 25: [6] Fillingham, D. (2007). Can lean save lives? Leadership in Health Services, 20(4): [7] Furman, C. (2005). Implementing a patient safety alert system. Nursing Economics, 23: [8] Heuvel, J., Does, R., and Koning, H. (2006). Lean six sigma in a hospital. International Journal of Six Sigma and Competitive Advantage, 2(4): [9] Jimmerson, C., Weber, D., and Sobek, D. (2005). Reducing waste and errors: piloting lean principles at intermountain healthcare. Joint Commission Journal an Quality and Patient Safety, 31: [10] Kaplan, G. and Patterson, S. (2008). Seeking perfection in healthcare: A case study in adopting Toyota production system methods. Healthcare Executive, 23(3): [11] Kim, C., Hayman, J., and et al. (2007). The application of lean thinking to the care of patients with bone and brain metastasis with radiation therapy. Journal of Oncology Practice, 3(4): [12] Koning, H., Verver, J., and et al. (2006). Lean six sigma in healthcare. Journal for Healthcare Quality, 28(2):4 11. [13] Laursen, M., Gertsen, F., and Johanson, J. (2003). Applying lean thinking in hospitals exploring implementation difficulties. Center for Industrial Production: Denmark. [14] Manos, A., Sattler, M., and Alukal, G. (2006). Make healthcare lean. Quality Progress, 39(7): [15] Miller, D. (2005). Going lean in health care. Institute for Healthcare Improvement. [16] Persoon, T., Zaleski, S., and Frerichs, J. (2006). Improving preanalytic processes using the principles of lean production (Toyota production system). American Journal of Clinical Pathology, 125(1): [17] Towne, J. (2006). Going lean streamlines processes, empowers staff and enhances care. Hospitals & Health Networks, 80(10): [18] Tragardh, B. and Lindberg, K. (2004). Curing a meagre health care system by lean methods translating chains of care in the swedish health care sector. International Journal of Health Planning and Management, 19(4): [19] Weber, D. (2006). Toyota-style management drives virginia mason. Physician Executive, 32(1): [20] Workman-Germann, J. and Haag, H. (2007). Implementing lean six sigma methodologies in the radiology department of a hospital healthcare system. American Society of Engineering Education. [21] Zidel, T. (2006). A lean guide to transforming healthcare: how to implement lean principles in hospitals, medical offices, clinics, and other healthcare organizations. Milwaukee, WI. Quality Press, IJMSEM for contribution: [email protected]