Dr. Robert Wacher interviews Dr. Richard Shannon about applications of lean and Toyota methods and culture to healthcare quality and patient safety. Dr. Shannon talks about how lessons from Toyota have led to increased staff and clinician engagement in quality improvement, namely dramatic reductions in hospital-acquired infections. This improves patient safety and quality, reduces costs, and frees up capacity (potentially reducing the need for expensive construction efforts).

This article was published in the July/Aug 2010 edition of the Journal of Hospital Medicine, a publication geared toward hospitalists (MDs).Authors Mark Graban and Amit Prachand provide commentary about the role of "respect of people" in data collection and improvement related to lean in a hospital. They draw a comparison that doctors and nurses should not be treated merely as "subjects" of observation by lean improvement efforts. Rather, they should be included as "scientists", directly engaged in the process themselves.Note: Registration and/or subscription required.

Akron/Canton "Smart Business" features Healthcare Value Leaders Network member Akron Children's Hospital in a front page article, where CEO William Considine talks, at length, about getting people enaged and on-board with lean. Considine emphasizes the core Lean principle of respect for people and how that engagement leads to major improvements.From the article:“We’re going to them and saying, ‘You know your work better than anybody. We want to empower you and give you the resources to look at ways to improve your efficiencies,’” Considine says. “And they love being a part of it.”Akron Children’s has always had a commitment of continuous improvement in services and efficiency. That commitment led the pediatric hospital to start implementing Lean Six Sigma two and a half years ago.Along with the processes and methodologies, Considine realized Lean Six Sigma is also about enhancing your culture, engaging employees and empowering them to improve.

This front-page story from the Denver Post highlights the cost savings and capacity increases created by lean at Denver Health.The article discusses improvements in these areas:LaboratoryEmergency departmentMedication ordersMaintenance

Cleveland Clinic and their lean efforts are featured in this U.S. News and World Report article with the subtitle "How the Cleveland Clinic is applying manufacturing principles to improve patient care."From the article:"That transformation is part of an unusual effort to bring the best practices of manufacturing to the hospital setting. Over the past five years, the clinic has assembled a 50-person team focused solely on "continuous improvement," or Kaizen, the Japanese word for "making things better." Most of the team members are engineers with experience far removed from healthcare. The efficiency experts quickly found out why healthcare isn't just another industry. Whereas higher profits might be the unambiguous goal at a corporation, doctors and nurses were not about to embrace any change that improved work flow without proof that it wouldn't lower the quality of care. "You cannot issue an edict," says team director Darryl Greene, who arrived at the clinic after a career spent improving processes at appliance makers and financial institutions. "You have to sell each doctor on the value, using data and results."

The link below contains an audio interview with John Toussaint, MD, co-author of the LEI book "On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry."The first Q&A:Q I realize that it's a few months off yet, and you probably haven't finalized your remarks, but what are some of the challenges that you intend to address in your keynote speech in Baltimore? Some of the messages you're taking with you?A I think that this is about leadership behavior. The tools are the tools, the tools are important, you've got to learn the tools, but you can learn the tools. The hard part is the people part. What does a lean leader look like? That's what I'll be focussing on, what it takes to be an effective lean leader. It means, pretty much, that you have to change everything that you've learned in business school, or medical school, or nursing school, and you have to pretty much retool yourself, because our existing education system is turning out autocratic control freaks who manage by the numbers, and they don't know anything about quality improvement, and they don't know how to manage a group of people to actually achieve 100% reliable results. If we don't change ourselves as leaders, we will never be able to transform our companies.

Instead of requiring patients to move from department to department to receive their care, a process typical in most cancer centers, the team created the "non-moving patient" care model. In the new Frauenshuh Cancer Center at Park Nicollet, patients remain in their own comfortable room with views of a healing garden, while caregivers come to them. Services rendered in the patient's room include: lab draws, nursing assessment, physician exam, IV therapy administration and the scheduling of future appointments.

The Sunday New York Times Business section featured a front page article about lean in healthcare. The main focus of the article was Seattle Children's Hospital, a member of the Healthcare Value Leaders Network.The article also mentioned other Network members:Akron Children's HospitalBeth Israel DeaconessPark NicolletThe piece highlighted not just cost and efficiency improvement, but quality and waiting time improvements, as well.

Children's Medical Center, Dallas, has built upon their Lean efforts to engage employees in a new "green initiative," reinforced the dual Lean principles of "Respect for People" and reducing waste.From the article:"Respect, develop, and empower employees. The members of the laboratory’s LEAN Green Team have been given the power to improve the lab in ways outside of their job descriptions, and all employees can be involved and offer ideas for improvement. All laboratory employees are encouraged to add value in ways that provide both professional and personal fulfillment. One way to do this is to join a committee with a focus aligned with a personal interest, and the LEAN Green Team is an option if one is passionate about being green."

Learn how Cincinnati Children's Hospital Medical Center (CCHMC) is striving to be the "best at getting better".

During the Transformational Leadership webinar, many of you asked for the list of related books and articles that presenter Jim Luckman cited. He has provided the list as a chart at the end of his answers to the following questions that we couldn’t get to during the one-hour webinar.

AHA News features McLeod Regional Medical Center, a member of the Healthcare Value Leaders Nework, and their clinical and process quality improvement efforts with lean and Toyota methods.From the start of the article:Marie Segars, administrator of McLeod Regional Medical Center in Florence, SC, recalls a time not long ago when "quality was paperwork. It just wasn't seen as integral to our everyday activities." That changed a decade ago at McLeod when the hospital decided to take a physician-led, data-driven approach to improving quality of care. Segars characterizes the move as highly unconventional at the time. But the resulting improvements in patient outcomes, along with McLeod's success eliminating waste and redundancies in its operations, have earned it the 2010 AHA-McKesson Quest for Quality Prize. The prize recognizes the Institute of Medicine's six quality aims of safety, patient-centeredness, effectiveness, efficiency, timeliness and equity. The also includes quotes from their CEO Rob Colones and a number of physicians talking about their participation in quality improvement efforts.

Foreword from On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry"Across the world for nearly a century, managers and front-line workers have been steadily learning about the power of rigorous processes to create more value for customers with less waste of every sort – time, defects, human effort, capital investment, injuries. The most accomplished practitioner of these methods through much of the past 60 years has been the Toyota company, but recently many organizations in a wide range of industries far beyond manufacturing have applied rigorous process management—often called lean thinking—to their core activities. When customer value is clearly understood and managers and employees at every level are creatively engaged in dramatically improving traditional processes, the results are invariably highly positive.""Curiously healthcare, with its strong base in the scientific method of rigorous experiments, was largely absent from this movement until recently."

Introduction to the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry"In the hospitals and clinics of the ThedaCare medical system in Wisconsin’s Fox River Valley, we have learned that every medical act is a series of steps that can be examined and improved. By investigating these steps, and the path that patients take through our hospitals and clinics, we have learned to identify value from the patient’s point of view and to start getting rid of the waste that clogs the system of healthcare delivery."Read the full introduction to On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry.

An excerpt from On the Mend: Revolutionizing Healthcare to Save Lives and Transform the IndustryChapter 2: Focus on the PatientIt was just after dinner on a bitterly cold night in March 2007 that Myrtle Bellis took a turn for the worse. Her skin grew pale and clammy, her heartbeat skipped and fluttered; she could not catch a full breath. As Myrtle lost and regained consciousness, her daughter Cindy telephoned for an ambulance and gathered up their coats.Read the entire chapter from On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry.

Q&A with John Toussaint, MD, and Roger Gerard, PhD authors of On the Mend: Revolutionizing Healthcare to Save Lives and Transform the IndustryQ: Lean originated in manufacturing; how does it apply to healthcare? Like lean manufacturing, lean healthcare strives to increase value to patients by taking the waste out of processes and improving quality. Nationwide, there is a growing emphasis on continuous quality improvement, cost reduction, and increased patient value — the same type of principles originally applied in manufacturing.Manufacturers that have diligently and thoroughly applied lean thinking have reaped steady productivity gains while reducing errors and improving the customer and employee experience. Imagine the results that similar improvements could bring in healthcare.Read the rest of the Q&A with authors John Toussaint and Roger Gerard.

See the Table of Contents from the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry

The Lehigh Valley Heath Network reports about their use of Lean methods in billing and coding operations. Lehigh Valley is a member of the Healthcare Value Leaders Network. From the article:"When the economic downturn began, colleagues in our medical coding and clinical outcomes department looked at the big picture of how they fit into our organization. "We wanted to ensure that we were applying lean tools and operating as efficiently as possible," director Carolyn Murphy says. "Coding sustains hospital cash flow, so we knew that any improvements we could make would have a positive impact on overall finances." They strived to meet a goal of increasing productivity by more than 20 percent, while simultaneously eliminating $300,000 in outsourced coding services annually, without hiring any new employees."

This article describes the lean work being done at the Kalamazoo, MI–based Borgess Ambulatory Care (BAC) organization. BAC is being assisted by the University of Michigan and Blue Cross Blue Shield of Michigan. Results from their improvements include:wait time for pediatric well visits was reduced from 60 days to eight daysmammography patients saw their wait times for follow-up testing after initial screening drop from 19 days to three days  

From the Emergency Department, Hôtel Dieu Grace Hospital, Windsor, Ontario, the first Canadian journal publication of lean healthcare results in the Emergency Department.A free news article about the journal article can be found here: "Assembly required: Health care from the Toyota factory floor”The abstract:Objective: In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds. Methods: In 2005 all staff in the ED at Hôtel Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value stream mapping, just in time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project. Results: Our ED has achieved major improvements in depart mental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles. Conclusion: Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED. Note: access to the full article requres a paid subscriptionHôtel Dieu Grace Hospital is a member of the Healthcare Value Leaders Network.

McLeod Medical Center in South Carolina, a member of the Healthcare Value Leaders Network, was featured in the news.From the article:"To find ways to save money, McLeod officials actually counted the steps McLeod nurses and other staffer take to reach supplies. As a result, the supplies were moved closer, which helped save time, money and improved bedside care. Operational efficiency at McLeod is supported by a program or method known as Operational Effectiveness. McLeod’s improvement teams analyze processes and work flow to reduce steps, reduce barriers and remove waste from the system of care, according to McLeod officials."

This article highlights some of ThedaCare's improvements, including growth (more revenue), reductions in patient waiting time, and improved productivity in the radiology oncology department. This was done through a series of week-long "Rapid Improvement Events" (often known as Kaizen Events), where staff members and leaders identify waste and design a new process. Free access through March 31, 2010, open to HFMA members only after that.

Are hospitals and their leaders feeling less confident about lean principles and lean methods because of Toyota's recent quality problems? Not so, says this Canadian article. The article features quotes from leaders including Dr. Michel Tetreault, president and CEO of St. Boniface General Hospital in Winnipeg. St. Boniface is a member of the Healthcare Value Leaders Network.

This Healthcare Financial Management Association (HFMA) article features a number of organizations, including ThedaCare.ThedaCare's results from using lean methods in radiology oncology included:A $900,000 increase in gross revenue from 2008 to 2009 and a 24 percent increase in gross revenue since the initiative began in the department in 2006A 63 percent reduction since 2006 in wait time from referral to treatment, down to six business days A 30 percent improvement in productivityThe ability to improve revenue and productivity without laying off staff (and to provide raises to staff last year)A key part of the success was their realization that reaching the 95th percentile in productivity was not enough, that they pushed to make a serious impact on improving patient care.

From the website leanROI.org, here is an interview with John Toussaint, M.D., CEO of the ThedaCare Center for Healthcare Value.Main Page: http://www.leanroi.org/contributors/johntoussaintmdFrom the beginning of the interview:"I think ROI is frankly not the right way to look at this. As the CEO I was interested in total organizational performance. And so what I measured was what’s our operating income year over year, is it improving or not? Are expenses improving year over year? Is our productivity improving year over year? Is our quality improving year over year?"Long- and Short-term ROIGetting StartedWhat Lean Means to MeCulture ChangeCourse Corrections and SustainabilityLeadership

The article summarizes the first few years of effort at Akron Children's Hospital in Ohio. Benefits from their use of Lean and Six Sigma methods include:Avoidance of a $3.6 million expansion of a sterile processing departmentCost savings of $708,000 from the first 28 lean projectsImprovements are staff-driven, based on their analysis of the current process:"But after an intensive look at the way instruments are cleaned, sterilized and delivered to surgery, the staff was able to speed up the process with some small changes, all within five days.The ideas were simple and cheap — things like knocking out a half wall for more visibility, hanging up signs to let people know where supplies go and assigning workers specific tasks each day, rather than having the same people assemble equipment and then deliver it."

Dr. Atul Gawande's new book, "The Checklist Manifesto: How to Get Things Right" has many conceptual ties to Lean. He was recently interviewed on NPR (text and audio available), where he talks about the benefits of checklists (a form of "standardized work" and also a form of "mistake proofing"). He also discusses the challenges of getting this powerful methodology to be more widely adopted.

The article is an overview of how Lean applies in healthcare and what some of the leading organizations are accomplishing with Lean. The article features ThedaCare (including the story of how a manufacturing, Ariens, helped get them started), Denver Health, and Elkhart General Hospital.Results cited include:ThedaCare has reduced "door to balloon" time from 91 minutes to 37 minutesPost-cardiac-surgery length of stay was reduced from 6.2 days to 4.8 days at ThedaCareDenver Health generated an additional $520,000 since 2007, using Lean to create more capacityDenver Health boosted revenue by $2.3 million by improving processes so they billed for all of the care they providedDenver Health has reduced costs by a total of $28.6 million

A Cambridge, Ontario hospital has saved $3 million through Lean and employee suggestions in the past year. "Staff offered more than 200 ideas since September that helped find $3 million in annual savings. These include work-schedule changes, smarter ways to offer care, and more efficient ordering of supplies." The hospital has made a commitment to staff that workforce reductions will be done only through attrition, not layoffs. This is key for gettting staff engaged in helping the hospital reduce its operating deficit while also improving patient care.

This feature story in Newsweek includes Lean as one part of the Cleveland Clinic formula for excellent healthcare. It says:"A century after Henry Ford began building cars on an assembly line, Cleveland Clinic has brought that technique to medicine, updated to reflect the latest Japanese-inspired thinking on "lean manufacturing" and "continuous-cycle improvement." Cleveland Clinic is a hospital trying to be a Toyota factory."Later in the article, their value stream mapping efforts and process improvement team are featured.

This article from the Jacksonville Business Journal highlights lean improvements in four healthcare organizations:NemoursBahri Dental CareMayo Clinic FloridaBaptist HealthThe short blurbs on each organization highlights improvements in patient care - reduced waiting times and reduced costs.

Trois-Riveres Hospital in Quebec underwent a four-month lean implementation in late 2008, leading to impressive results in their emergency department.Patient length of stay fell from 17 hours to 4Department throughput increased by 40%The chief of emergency describes a shift from a doctor-centered world to a patient-focused department and processes. The department focused on eliminating non value adding time for nurses and they reconfigured the registration and triage patient flow to prevent waiting time and to ensure that the patient only had to be seen by a doctor once. The work environment is described to be less stressful and physicians make more money because they are seeing more patients.From ComputerWorld Canada

Full text of this article about a Healthcare Value Leaders Network member is reprinted with permission of CME Manitoba, visit their website at www.daretocompete.ca.In the past year and a half, St. Boniface Hospital has been moving towards more Lean processes to improve patient care and the way the facility is run. The hospital got some “interesting tastes” of Lean thinking two years ago, and since then the board and executive have enthusiastically embraced the concept.Chief Medical Officer Dr. Bruce Roe says that the hospital has been implementing Lean processes in two main value streams. The first involves patients with suspected heart disease who present themselves at emergency. “We do a medical assessment and EKG within 15 minutes of seeing them,”Dr. Roe says. In the other value stream, the hospital has developed a system to move some patients directly to a ward from emergency after a surgeon or a member of the surgical team has assessed them.“In both streams, making the diagnosis more expeditiously gets the patients into treatment much faster”, Dr. Roe explains. The hospital is also in the process of adding more Lean thinking value streams including: how to assess the 90% of emergency patients who do not require a hospital stay, how to improve efficiency in the clinical supply chain, and how to create more capacity to treat heart or COPD patients.Another Lean tool that has worked well for the hospital is the Perfect Care Planner. It is a system that has been introduced on two surgical units, making it very visible for staff to know exactly what is required before patients can be discharged.

This article features Lean thinking and how that led to the design of the Collaborative Care model at ThedaCare. The six "best practices" elements listed in the article are: Collaborative rounding upon admission Evidence-based plans of care Nurse as manager of care Tollgates Electronic Medical Record Purposeful design of physical space The article includes a number of comments from Kathryn Correia, senior vice president of ThedaCare and president of Appleton Medical Center and ThedaClark Medical Center in Neenah, Wisconsin.

This is a news story that features comments from Dr. Eric W. Dickson, professor of emergency medicine at the University of Massachusetts Medical School in Worcester. The story has quotes and references from a new study in the Annals of Emregency Medicine about using Lean and Toyota methods in hospital emergency departments.Dickson emphasizes the idea of engaging front-line staff in improvement efforts, saying:"Dickson said that there were two key factors. One was that ideas for improvements came from the "front lines" -- the doctors, nurses and others working in the ER -- and not from management. The other was that management, while not dictating change, was actively involved in making sure all employees tried to implement changes."Every emergency department is different," Dickson said, explaining that there is no big, "magic-bullet" change that makes ER more efficient. "It's hundreds of tiny changes that add up.""

The lead author on this journal article is Dr. Eric W. Dickson, professor of emergency medicine at the University of Massachusetts Medical School.The abstract begins:"Background: “Lean” is a set of principles and techniques that drive organizations to continually add value to the product they deliver by enhancing process steps that are necessary, relevant, and valuable while eliminating those that fail to add value. Lean has been used in manufacturing for decades and has been associated with enhanced product quality and overall corporate success.Objectives: To evaluate whether the adoption of Lean principles by an Emergency Department (ED) improves the value of emergency care delivered. Methods: Beginning in December 2005, we implemented a variety of Lean techniques in an effort to enhance patient and staff satisfaction. The implementation followed a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation. Process redesign focused on generating improvement ideas from frontline workers across all departmental units. Value-based and operational outcome measures, including patient satisfaction, expense per patient, ED length of stay (LOS), and patient volume were compared for calendar year 2005 (pre-Lean) and periodically after 2006 (post-Lean)."Access to the full text is limited, unless you are a subscriber or are willing to pay for the article ($31 for those who do not already have access).

Seven members of the Healthcare Value Leaders Network were named recipients of the Consumer Choice award, as a leading quality healthcare provider and "most preferred" in their market. This award is based on surveys of patients and community members.Johns Hopkins HospitalLawrence & Memorial HospitalLehigh Valley Hospital & Health NetworkMcLeod Regional Medical CenterThedaCare and Theda Clark Medical Center (dual awards)Iowa Health System: St. Luke's Regional Medical Center and Allen Hospital (dual awards)University of Michigan Health SystemAwards like this demonstrate that the quality and value provided by these organizations is recognized by their customers.Click the "read more" link for a full list of winners from around the country and for more about the distinction.

St. Clair Hospital, in Pittsburgh, has used Lean and Toyota methods to reduce waiting times and improve patient care. This article from the Pittsburgh Business Journal highlights their leadership and staff engagement efforts. "Standardization of equipment, training and procedures has helped the hospital all but eliminate infections that are picked up with the insertion of central lines in intensive care unit patients — they haven’t had a central line infection in two years."

This article discusses linkages between Toyota practices (the automotive industry) and two companies in the Toronto area: Bombardier (aerospace) and St. Joseph's healthcare.The piece, published in the Financial Post, highlights improvements from both organizations. For Bombardier, this includes improved cost and profitability. For St. Joseph's, waiting times and patient care in the Emergency Department have been improved through the efforts of physicians, staff, and administrators. 90% of patients are seen within 4 hours (compared to just 50% before).The article also highlights how Toyota has volunteered and provided help to St. Joseph's.

Here is a public policy statement from the ThedaCare Center for Healthcare Value, a partner in the Healthcare Value Leaders Network.It begins:"The current debate about healthcare reform in America is fundamentally flawed. A new government sponsored health plan or a new tax to pay for reform will do little to make high quality healthcare more affordable for more people. Unless we get serious about changing the way we deliver healthcare and the way we pay for care in this country, costs will only continue to escalate exponentially."

Here is a Washington Post op-ed from the President & Chief Operating Officer of Seattle Children's Hospital, Pat Hagan. The results that Hagan cites from Seattle Children's are impressive, including: "Patient days on ventilators have been safely reduced by 26 percent" (which reduces risks of infection) Saving $2.5 million on supplies in the first year alone "Reduced cardiac surgical site infections and hospital-acquired blood stream infection rates by 50 percent in just three years" "Seattle Children's has reduced direct per-patient costs by 3.7 percent" In his piece, Hagan references Toyota and a number of Lean management methods, including: Standardized work Error proofing Visual management

This article from the Milwaukee Journal-Sentinel features Gundersen Lutheran health system, a member of the Healthcare Value Leaders Network and it’s highly standardized, high-quality, low cost care. As the article points out, “Medicare spent 30% less on average for each beneficiary in the La Crosse area [which includes Gundersen] than the national average in 2006, the most recent year for which data is available, according to the Dartmouth Atlas of Health Care. It spent 64.5% less than in Miami and 61% less than in McAllen, Texas, the two most costly areas. And it spent 23% less than in the Milwaukee area.” While the article does not specifically call out Lean methods, the themes of customer focus (patient focus), standardized work, and culture are clear and would be recognizable to lean thinkers. 

This USA Today article highlights some of the opportunities and successes that hospitals are having using Lean methods such as kanban, just-in-time, and other Lean practices.The New York City Health and Hospitals Corp. has recognized a one-time savings of $5 million from implementing a "just-in-time" materials delivery system. By rationalizing the types of gloves that physicians and staff use, they are also saving $4 million a year in supply costs. St. Vincent Indianapolis Hospital used Lean to help reduce the number of walking steps for emergency department nurses by 78%. Delnor Hospital in Illinois was able to use Lean redesign to eliminate the need for a planned $80 million expansion.  

Published in the September/October 2009 edition of the journal "Health Affairs," Dr. John Toussaint, CEO emeritus of ThedaCare and CEO of the ThedaCare Center for Healthcare Value, writes about how "the U.S. government needs to reform the insurance payment system so that it rewards good medicine instead of waste." Toussaint writes about the improvements that ThedaCare has made using an improvement methodology based on "lean" and the Toyota Production System.The article describes improvements and results in areas such as:Heart attack careNewborn deliveryPrimary care ("collaborative care")Toussaint shares results from ThedaCare's work and makes recommendations about how public policy and encourage this type of innovation rather than punishing quality and cost improvement from a financial standpoint. Note: This article requires a paid subscription to Health Affairs magazine

St. Joseph Medical Center in Towson, MD hired a Toyota veteran, Dave Norton, to lead their lean transformation efforts. Initial improvements are reported in Emergency Department flow and length of stay, as well as improvements in getting admitted patients into beds without delay. Quoting from the article,"St. Joseph plans to implement lean processes in operating rooms next. While the process will save the hospital money, Norton said that is not the priority.“I’d like to think we’re saving lives rather than focusing on saving dollars,” he said. “Obviously the monetary savings come later, but the point is saving lives.”"

CEO of Park Nicollet, David Wessner, writes about the lean thought process involved in working to prevent and eliminate patient falls. There are multiple "countermeasures" put in place to tackle this problem, including hourly rounding, low beds, post-fall huddles -- examples of root cause problem solving, standardized work, and visual management, among other methods. Posted at the "Lean Healthcare Grand Rounds" blog.

This article summarizes how Denver Health, under the leadership of their CEO, Dr. Patty Gabow, started their lean journey in response to a previous annual loss of $6M. Denver Health had executive involvement and formed a steering committee that prioritized intitial lean work in five areas:Access to careBillingOutpatient flowInpatient flowOperating room (OR) flow One patient-centered improvement was: "The OR flow team “significantly increased the number of patients who received antibiotics within the appropriate time frame before surgery--one hour, as recommended by national guidelines--from 80 percent at baseline to 96 percent in July 2006."Their total financial savings are described as: "Denver Health has realized cost savings and revenue enhancements totaling more than $11 million in the past three years." The article also captures their "lessons learned" and how lean has become "a way of life" at Denver Health. 

U.S. Representative Steve Kagen (D, WI) praised ThedaCare in a news interview, saying: "The other savings and eliminating of waste is the leadership that the ThedaCare Center for Health Care Value brings to the table. There, they've been able to demonstrate that they can improve quality and decrease cost by 25 percent caring for you at the hospital. If you translate that across the country, that's $40 billion a year of savings."

One of a series of case studies on the "Hospitals in Pursuit of Excellence" webpage, this article highlights Fairfield Medical Center in Lancaster Ohio, a 220-bed hospital that used Lean and Six Sigma to reduce pressure ulcers (aka bed sores) by half. Documentation was improved and nurses had more time for patient care as a result of their waste-reduction efforts. Click here for more case studies.

Jefferson Healthcare CEO Vic Dirksen is an advocate for lean methods, as described in this article from a Washington local newspaper. In " almost any conversation Dirksen has these days includes comments about Lean, a program that employs the so-called Toyota management method." Dirksen adds, ""I wish we had gone to Lean when we first learned about it. We're only in Phase 1." 40% of employees have been trained and initial projects have helped avoid outsourcing in laundry services and they have increased capacity in patient clinics.

Dr. Ted Eytan writes, on his blog, about going to Group Health Cooperative in Seattle to see their primary care and medical home area. The blog post discusses their visual management practices and has photos of their "visual room" for tracking the roll out of lean practices across 26 clinics in their system. "What [they] showed me was a whole room of visual displays used to track the progress of the reinvention of primary care. This includes everything from leadership/manager standard work, call management, use of virtual medicine, preparation for visits, as well as the vision, strategic plans, outcomes, and staffing."

McLeod Health CEO Rob Colones writes, in his blog, about McLeod being part of the Healthcare Value Leaders Network, a partnership between LEI and the ThedaCare Center for Healthcare Value. McLeod's program is called Operational Effectiveness and began in 2007.

This article from the Ann Arbor Business Review features the lean adoption efforts at the University of Michigan Health System, featuring Dr. Jack Billi, the associate vice president for medical affairs at the University of Michigan and an associate dean at U-M's medical school. U-M formally adopted lean in 2004 as their overall improvement methodology. "(Our goal) is to use lean thinking as a business strategy for how we will accomplish ... the best quality, highest safety, most efficient, most appropriate and best customer service that we can," he said. One area of success came at MedSport, where appointments used to take 23 days due to numerous steps the staff had to take. After undergoing scrutiny of the lean principles, that days-long effort was reduced to 2.5 minutes and one phone call for patients.

This article documents improvements in the British Columbia health system in cataract surgery. Lean methods were applied to reduce waste and improve patient care. One documented savings in the story was a $450k reduction in unnecessary anesthesia expense, using local sedation when full anesthesia was not really necessary (a good example of eliminating the waste of "overprocessing"). There are a number of quots from surgeons and hospital leaders, as well as some discussion of improving flow through the emergency department value stream and improvements in a nursing station.

This article about ThedaCare discusses cultural values of candor and collaboration as being key to their Lean "ThedaCare Improvement System" efforts. ThedaCare has moved beyond sole reliance on week-long "Rapid Improvement Events" by adding work to develop a culture of "continuous daily improvement" with hospital staff driving improvements. Examples are cited from areas including nursing and a primary care clinic. Published by the Association for Manufacturing Excellence "Target" Magazine

While not mentioning lean specifically, this article captures some of the data for the improvements in the ThedaCare emergency department for patients who arrive with chest pains. The "Code STEMI" process, developed through the ThedaCare Improvement System and lean methodology, has led to improved patient care. "ThedaCare also is listed 28th out of the 824 hospitals in the NCDR database. According to the NCDR, 96.2 percent of STEMI patients at ThedaCare experience door-to-balloon times less than 90 minutes. The Code STEMI process is resulting in improved outcomes, fewer complications, and higher survival rates for heart attack patients.v"This is a testament to the doctors, nurses, managers, and other staff, along with the area’s first responders and the leaders of many rural hospitals," said Kathryn Correia, president of Appleton Medical Center (AMC) and Theda Clark Medical Center (Theda Clark), and senior vice president of ThedaCare."

This article highlights hospitals that are eliminating waste in healthcare. The author writes: "Researchers believe there is 30 percent "quality waste" in U.S. health care; that is, unnecessary costs due to care that is inappropriate, inefficient or unsafe." The CEO of Heartland Health, Lowell Kruse, said: "You have to build a culture that relentlessly attacks broken business processes; for example, standardizing a confusing welter of surgical supplies. And, of course, your physicians and employees have to regard these activities and countless others as a benefit to patients rather than a threat to profits." In Appleton, Wisconsin, Dr. John Toussaint insists that "quality waste" adds up to a stunning 40 to 50 percent of costs. Until recently Toussaint ran ThedaCare, whose systematic efforts to improve care and lower costs were profiled in a case study by Harvard Business School superstar expert Michael Porter. The column also makes allusion to the partnership between the LEI and the ThedaCare Center for Healthcare Value. 

This article, from the journal Healthcare Quarterly, is a practical overview and introduction to lean principles in healthcare. With examples and data compiled from interviews with five Canadian hospitals, the piece emphasizes a number of key points, including: 1) You can get started with lean by spending a few hours observing work and identifying waste; 2) A combination of executive support and outside Lean expertise is an important mix; 3) The lean expertise must come in the form of teaching to ensure that the Lean process is sustainable once the consultant leaves; 4) Engage physicians and staff by focusing on "what's in it for them?"; 5) Alleviate staff fears about the word "lean" by promising "no layoffs as a result of lean." (note: fee required to view entire article)

Two-page PDF file from Virginia Mason gives a concise overview of lean methods in healthcare answering questions such as: Can car-making methods be adapted to health care? Why did Virginia Mason adopt TPS manufacturing principles? How does VMPS work? What are the benefits and results of VMPS? The second page are examples and brief success stories from areas such as cancer treatment, endoscopy, nursing, pediatric clinics with benefits such as improved patient safety, fewer falls, cost savings, revenue enhancement through capacity increases, and creating more time for nurses to provide patient care.

Tamra Kaplan, new COO at LBMMC, formerly led the hospital's lean efforts, called "MC*21": "Kaplan incorporated the principles of the Toyota Production System (LEAN), a management philosophy that emphasizes creating a sense of purpose to transform business and cultures. Under Kaplan`s leadership, the [first] year of MC*21 resulted in an estimated $2.1 million annualized return, and fiscal year 2009 will yield a three-year return of $15.3 million."

As part of its lean transformation,Virginia Mason Medical Center, Seattle, contacted area employers to ask what they needed most from hospital visits. Immediate appointments and getting the right treatment at the right times, is what the hospital heard. As a result, treatment time at the back clinic was cut from an average of 66 days to 12. (Published by CBS Evening News.)

Lean thinking in healthcare is the efficient use of staff, resources, and technology to provide the highest level of service possible to the ultimate healthcare customer: the patient. The story gives an overview of how the five-step lean thinking thought process applies to healthcare along with examples of waste. (Published in the Journal of the American Health Information Management Association.)

Lean is a complete business system that relies on people development. (Published by IndustryWeek.)

The ASHP presents an audio webinar about Lean in pharmacy processes, presented by Carol Birk, M.S., R.Ph., Director of PharmaTAP, an engagement program of the Purdue University School of Pharmacy and Pharmaceutical Sciences and the Purdue Technical Assistance Program (TAP). The link below leads you to a briefing paper, webinar audio, and slides that were presented online.

Using lean concepts, Meadows Regional Medical Center cut in half the time a patient stays in its emergency room. The 122-bed facility in Vildatia, GA., has reduced ER stays from 247 minutes to 125 minutes, which means it can treat more patients. Two years ago, the unit saw 60 patients daily; it now treats 100 or more people daily. (Health Data Management.)

Read the Table of Contents for Follow the Learner.

From the PublisherThe purpose of Follow the Leader is to present a picture of how any organization can build a culture based on lean principles and tools. Why tell a story about a dental practice? First, everyone has been to the dentist. Every reader has a common frame of reference and therefore has experienced the processes and problems Dr. Bahri describes. Second, he happens to be one of the most dedicated and knowledgeable lean thinkers and practitioners in any field.Read the rest of the Introduction.

Part I: Creating a Lean PracticeIn this first section, Dr. Sami Bahri describes the evolution of Bahri Dental Group’s lean dental processes. What began in the 1980s with a personal commitment to reduce the long lead times before treatment, eventually led Dr. Bahri to “flow” the entire treatment system. He shares the “why” of lean, as well as the many experiments that he and his team undertook in order to learn and live a lean method of meeting the needs of every patient.Because lean has its roots in manufacturing, some of the terms in this section may be unfamiliar to readers with service or healthcare backgrounds. At the end of this chapter (pp. 30–34) you’ll find a chart of lean terms and their application in manufacturing and dentistry. This chart will also be helpful to readers in manufacturing who may want to see how familiar lean concepts and tools can be applied in nontraditional ways.Read the rest of this excerpt from Follow the Learner.

Akron Children's Hospital was considering a $3.6 million capital project to keep pace with demand for clean surgical instruments. But during a five-day kaizen event, staff members developed simple and less expensive alternatives by analyzing the way instruments were cleaned, sterilized, and delivered to surgery. The kaizen project boosted capacity from to 16,000 operations annually, up from 13,000 procedures. (Published by the Akron Beacon Journal.)

The Department of Pathology at Children’s Medical Center in Dallas is this year’s Medical Laboratory of the Year for 2009, an annual honor sponsored by Medical Laboratory Observer magazine. As a result of lean process improvements, specimen rework caused by missing information was eliminated and turnaround time on key tests, such as urinalyses, was cut, freeing staff to focus on patient care.  As part of the culture change,  a mistake is now viewed as a flawed process, and individual blame is discouraged, although accountability is strong. When mistakes occur, the process is studied for the root cause. Individual error is simply defined as not following the standard process. In another  innovation, a lab team conducts a weekly book study group targeted to managers and supervisors. (Published by Medical Laboratory Observer.)

St. Luke’s, SMDC Health System and a few other smaller healthcare providers in Northeastern Minnesota are using lean principles -- not just buying new equipment -- to improve care. For example, St. Luke's used value-stream mapping to improve workflow in its cardiac catheter lab. Improved lab processes can handle patient volume with one less technician. The extra technician was reassigned. Hospital officials said they expect the application of lean thinking to allow the unit to do more procedures without adding any people. (Posted on BusinessNorth.com.)

At British Columbia Women’s Hospital, a Toyota-based five-day workshop cut by 90% the time from when a new mother is ready to be discharged to when she leaves. Before the program, the discharge process took an average of 10 hours. Now, it takes about one hour. Psychiatric patients used to have to wait 10 days to be admitted to a bed. Since the workshop, it’s down to an average of 3 1⁄2 days. (Published by the Vancouver Sun.)

This article provides a summary of ThedaCare's lean journey, including improvements in their radiation oncology department. From the article:"The results have been consistantly significant. This year, the radiation oncology department improved productivity by 30 percent, increased gross revenue by 24 percent, and reduced the time from patient referral to treatment by 44 percent. Additionally, lean management has helped relieve overburned staff, allowing them to focus on patient care." The article also highlights ThedaCare's efforts to build a "hospital of the future" by designing space to match their "Collaborative Care" model of patient care."To date, the Collaborative Care Unit has experienced a 25 percent reduction in total cost of care and patient satisfaction is ranked at 100 percent."

Hotel-Dieu Grace Hospital in Windsor, Ontario has taken part in a pilot project for the province’s Flo Collaborative.  The program is designed to reduce the unnecessary length of hospital stay for elderly patients without acute illness.  Staff members have used lean techniques to identify and eliminate barriers that prevent a patient from being discharged.  Visual management systems play a prominent role in the effort, including a ‘traffic light’ system for each patient to indicate the timeframe for a patient’s discharge from the hospital.  Procedural improvements have already drastically reduced the length of hospital stay for many patients while maintaining the requisite level of care.  As an added benefit, patients are able to play a more active role in monitoring the progress of their own care. (Published by The Windsor Star online, Mar. 12, 2009.)

An interview of Mark Graban, author of the recently published book LeanHospitals,  in which he discusses the growing adoption of lean in healthcare institutions.Mark illustrates common areas of great opportunity such as wasted motion, and facility layout, and ultimately suggests that the greatest benefit of Lean as a management system in a hospital would be the improvements realized in patient safety and quality of care.(Published by Healthcare Construction + Operations News online, Nov 24, 2008.)

The Lean Health Initiative that started in northwest Minnesota in 2004 is slowly spreading across the state. State officials said the effort uses uses some of the same concepts used at companies like Marvin Windows and Arctic Cat to streamline production. Since 2004 the state has awarded 15 grants to train 4,700 workers at 30 hospitals and clinics at a cost of $3.7 million. The medical facilities have contributed $8.3 million to training. State officials said the effort produces three benefits: workers remain at facilities, the quality of healthcare and patient satisfaction increases, long-term costs remain steady because there are fewer steps in processes. (Published by Minnesota Public Radio, Dec. 29, 2008.)

A registered nurse explains briefly how some simple steps taken during a kaizen workshop improved the availability of wheelchairs, decreases searching time, and improved the cleanliness of chairs. (Published online by Lean Healthcare Exchange, Dec. 17, 2008.)

A year after a medical group in Albuquerque, NM, began applying lean concepts, such as a pull system for basic supplies, staff morale was up and the office had saved $16,000 in supplies. And doctors reported seeing more patients while working fewer hours because lean had "simplified their days," acording to a nurse. (Aired by KRQE News 13, Albuquerque, Dec. 23, 2008.)

In this article, Lesley Wright describes one of the largest challenges that Lean initiatives face in a healthcare organization. All too often there is a reluctance to adopt ideas from the Toyota Production System or Lean simply due to their origins in manufacturing. This article points out that the people-centric roots of TPS and Lean are a perfect fit in terms of content, but may require contextual repackaging to gain popularity in healthcare.(Published by Health Services Journal online Dec 1, 2008.)

At the Detroit Medical Center (DMC), CEO Mike Duggan claimed the application of lean principles helped the medical center return to profitability after years of loses. The medical center and several other area hospitals described how they are improving operations and patient care. At the DMC, employees studied patients journeys through the facility, eliminating nonvalue-adding steps. The result: shorter waiting times that attracted more patients. In the emergency room, the DMC cut the average wait from a couple of hours to 29 minutes, increasing business by nearly 30%, Duggan said. At Trinity Health, a 44-hospital system based in Novi, the lean effort generated savings "easily in the tens of millions" in 18 months, according to the hospital. (Published by The Detroit News, Nov. 6, 2008.)

To be successful, everything a National Health Service organization does should be based on lean principles. The chief executive of royal Bolton Hospital foundation trust explains how he and his staff put lean into practice. A key to the organization’s success with its lean program is enlisting staff commitment to finding ways to eliminate waste in their processes. “We have established an academy to give all 3,500 members of staff a lean mindset and skills,” says hospital CEO David Fillingham. (Published in Health Service Journal, October 17, 2008.)

With the launch of a pilot project, Children's Hospital joins ThedaCare in Appleton and Froedtert Hospital in Wauwatosa in implementing lean thinking in Wisconsin. (Published byThe Business Journal of Milwaukee,Oct. 6, 2008. NOTE: Subscription required.)

St. John’s Mercy Medical Center in St. Louis, Missouri began a transformation journey with the assistance and guidance of lean leaders from Boeing Co. This article outlines the progress made, starting with an initial project in the rehabilitation center. The process steps for a patient to see physiotherapists were reduced by nearly half, and flow of both patients and information is now simplified. Great improvements in quality of care, length of wait for visits and duration of patient stay are anticipated as the transformation efforts expand to 20 projects across multiple departments in the hospital.(Published by the St. Louis Post-Dispatch, Sept. 17, 2008.)

Built nearly 20 years ago, Markham Stouffville Hospital (Canada) felt a capacity pinch trying to handle a growing number of patients. The leadership team turned to lean thinking to remove waste from current processes while improving patient and staff satisfaction. "We look at things from the patient's perspective and find ways to make it better," said Janet Beed, president and CEO. Dr. Andrew Arcand, chief of the emergency department, said teams "looked at the way we do everything, from managing patient flows, to supply, to triage, to offloading ambulances. We put everything under the microscope and looked for ways to do things more efficiently and effectively." The story summarizes some of the improvements made during the initial kaizen workshops. (Published by Hospital News, August 2008.)

In Healthcare Executive, two executives at Virginia Mason Medical Center, which has adopted a lean management system based on Toyota's lean model, make the case that not only is the goal of zero defects possible in healthcare but it is absolutely necessary. An underlying problem is that while healthcare technology has advanced greatly since the 1950, its management systems have not.

"Lexicon is just a fancy word for dictionary—one that conveniently alliterates with “lean”—and like all dictionaries, there is a need for upgrades as usage changes and new terms emerge. This is therefore Version 4.0 of what we imagine will be a continuing effort to define and sharpen our language as we all move toward future states and ideal states. In this spirit, we hope to hear from Lean Community members about additional terms to include in future versions and about changing usage and changing business needs that may call for revised definitions and additional examples."Read the rest of the Introduction.

ThedaCare estimated that process improvements in 2005 and 2006 cut costs by $22 million annually, without layoffs or reducing quality, while reducing medical errors. It stopped tracking savings in 2007 after verifying the results. For example, an uncomplicated heart bypass, including physician fees, costs $30,400 at a ThedaCare hospital, based on what ThedaCare and its independent surgeons bill one large health insurer. That insurer pays $42,700 to $71,000 for the same procedure at hospitals in southeastern Wisconsin, according to Thedacare. The savings haven't compromised quality.ThedaCare's bypass mortality rate of 0.5% beats the Society of Thoracic Surgeons benchmark of 1.7%. ThedaCare's mortality rate for other bypass surgeries also beats national benchmarks. The company's goal is to eliminate the estimated 20% to 30% of medical spending that does nothing to improve patient care. "We are going to improve something every day," said John Toussaint, ThedaCare's chief executive. ThedaCare also is among a few healthcare systems such as Virginia Mason Medical Center in Seattle that uses the lean business system at Toyota Motor Corp.as a model for improvement. ThedaCare's improvement approach often starts with mapping the steps in an activity from when a patient schedules an appointment to billing and asking whether each step adds value from the customer's perspective. Much of the improvement work is done during the rapid improvement events, sessions that run from a few days to a full week and that typically involve seven to 12 people. They have responsibility of finding a better way to provide care, testing it and then implementing the changes. ThedaCare does three or four of the events a week. (Published by the Milwaukee Journal Sentinel, McClatchy-Tribune Information Services, March 31, 2008.)

A point-of-use system for consumable items used by doctors and nurses at MetroWest Medical Center, Framingham, MA, has been most effective in the special care nursery, where it has improved emergency care of infants. The self-contained units in the nursery include everything doctors and nurses might need to treat an infant just after birth. Supplies once stored in a disorganized fashion have been organized so restocking will occur before a unit is closed after use. (Published by MetroWest Daily News, March 21, 2008.)

Geoff Graham, director of facilities for Carter BloodCare in Texas, explains how lean concepts were applied to the process of separating blood into its different components for different patients. After the Sept. 11 terrorist attacks, Carter and other blood centers were overwhelmed by large numbers of donors. Carter also had to cope with increasing demand from the area's growing population and from patients living longer. Despite the regulations and standards that have to be met for handling blood products, engineers and staff were able to identify waste in time and effort such as walking back and forth across rooms, waiting for large batches of blood to be processed instead of smaller batches, or interrupting work to look for equipment. Graham said that a test "pod" was established to check the new process before expanding it. The changes have increased capacity from 750 blood units per shift to more than 1,100, plus an estimated $950,000 in process savings and cost avoidance. (Published by the Fort Worth Business Press, March 17, 2008.)

A 2008 study by Press Ganey Associates Inc. on patient satisfaction found that Iowa hospitals were the quickest in the country to provide emergency medical attention with an average emergency visit of two hours, 18 minutes compared to the national average of three hours, 42 minutes. Healthcare professionals cited such factors as Iowa's low rate of uninsured patients as affecting emergency visit times. But several of Iowa's largest medical centers pointed to the use of six sigma and lean techniques to identify and eliminate waste from emergency room processes as a factor in improving emergency department treatment times. (Published by Nurse.com, March 10, 2008)

Applying process improvement thinking to the Newton-Wellesley hospital radiology lab eliminated enough wasted steps to cut the median time elapsed from the end of check-in to the completion of the X-ray exam from nearly 40 minutes to less than 25 minutes. Some weeks it's down to 21 minutes. As a result, the hospital has dropped plans for a new machine, reports The Boston Globe. "We're treating more patients every year, but it doesn't seem as busy as it used to be," said Brian McIntosh, radiology operations manager, told the paper.

In an interview with the Redesigning Care blog at Health Affairs, former Virginia Mason CEO Gary Kaplan touches on the hospital's deployment of the Toyota Production System. (Published online by Health Affairs, July 10, 2007.)

See the Table of Contents from the book Managing to Learn.

Foreword, by Jim Womack, to the book Managing to Learn."I’m enormously excited about this book. John Shook’s Managing to Learn seeks to answer a simple but profound question: What is at the heart of lean management and lean leadership?"In addressing this question, Managing to Learn helps fill in the gap between our understanding of lean tools, such as value-stream mapping, and the sustainable application of these tools."Read the rest of the foreword.

Introduction to Managing to Learn.At Toyota, where I worked for more than 10 years, the way of thinking about problems and learning from them for more effective planning, decision-making, and execution is one of the secrets of the company’s success. The process by which the company identifies, frames, and then acts on problems and challenges at all levels—perhaps the key to its entire system of developing talent and continually deepening its knowledge and capabilities—can be found in the structure of its A3 process.Read the rest of the Introduction.

Chapter 1 of Managing to Learn.The term “A3” refers to an international-size piece of paper, one that is approximately 11-by-17 inches. Within Toyota and other lean companies, the term means much more.Toyota’s insight many years ago was that every issue an organization faces can and should be captured on a single sheet of paper. This enables everyone touching the issue to see through the same lens. While the basic thinking for an A3 (see pages 8–9) follows a common logic, the precise format and wording are flexible, and most organizations tweak the design to fit their unique requirements.Read the rest of the Introduction.

Chapter 2 of Managing to Learn.Acme Manufacturing is the U.S. subsidiary of a midsized Japanese manufacturing company. Five years ago the parent company launched its initial U.S. investment with the launch of its largest overseas factory. A current expansion plan for that plant is projected to double capacity and extend product lines. The expansion also will nearly double the size of the production organization.At the U.S. Acme site, manager Ken Sanderson has assigned middle manager Desi Porter the project of improving the document-translation process for the expansion. This translation process was fraught with problems during the plant’s startup, and, now with Sanderson’s mentoring, Porter has been charged with bringing such problems to light and proposing ways to improve the process. This seems simple enough, but for many companies, with the exception of those like Toyota, looking for problems is counter to corporate culture.Read the rest of Chapter 2.

See a video report by WCCO in Minnesota about a kaizen event at Methodist Hospital in St. Louis Park, Minn.

In the time it takes you to read this article in the Harvard Business Review, five to seven patients will die due to infections or errors suffered in U.S. hospitals. But some hospitals are making impressive improvements without the threat of new laws or market tinkering. They've learned to tighly couple the process of doing work to a process of doing it better, according to Steven Spear, a senior fellow at the Institute for Healthcare Improvement, Cambridge, MA. (Follow the link for how to obtain the full article from HBR.)