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.

This article, from the journal Journal for Healthcare Quality, highlights improvements in the medication delivery value stream in a hospital in the midwestern United States.The abstract states:The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital.

Steven Bradt, a graduate student at the University of Manchester business school in the UK, is conducting PhD research and has this online survey, link is below.Please consider taking 15 minutes to fill it out. I have given Steven some advice on his work and the survey and am really interested to see the results of his research. Steve will not share your email address... his privacy statement is on the first page of the survey, which can be found here:http://www.surveymonkey.com/s/SXZPFYBHe will report some summarized results to those to leave their email address with their response.

Professor John Grout and John Toussaint, M.D., combine their lean experience to write a peer-reviewed journal article from Indiana University's "Business Horizons".Grout teaches an LEI workshop called Mistake-Proofing Healthcare: Designing Processes to Reduce Medical Errors. Toussaint is CEO of the ThedaCare Center for Healthcare Value, a partner in the Healthcare Value Leaders.The link below is a PDF file of the article.

Published in the International Journal for Quality in Health Care 2009 21(5):309-310. The authors conclude that Lean methods are worth pursuing in healthcare, but recommend more of a focus on creating evidence that Lean works, not just cheer leading and reporting success stories. The authors propose three types of "value" in healthcare to supplement the classic "Lean Thinking" definition: clinical, operational and experiential value.

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).

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

In this oft-cited Harvard Business Review piece, Dr. Steven J. Spear presents a framework for hospital improvement, called the 'Rules in Use.'Work is designed as a series of ongoing experiments that immediately reveal problems.Problems are addressed immediately through rapid experimentation.Solutions are disseminated adaptively through collaborative experimentation.People at all levels of the organization are taught to become experimentalists Spear makes the case that hospitals must move beyond a culture of ambiguity and workarounds.

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)

In this article from the International Journal of Emergency Medicine, the authors make the case for additional experimentation with Lean methods and further research into the benefits and results. They conclude "While further research is necessary, it appears that the increasing embrace of lean thinking and related methodologies to the health-care environment is warranted and results in improved patient care metrics, greater efficiency, and ultimately happier and healthier patients."

Published in the Journal of Hospital Medicine, Volume 1 Issue 3, Pages 191 - 199, Published Online: 5 Jun 2006 BACKGROUNDWith health care costs continuing to rise, a variety of process improvement methodologies have been proposed to address the reported inefficiencies in health care delivery. Lean production is one such method. The management philosophy and tools of lean production come from the manufacturing industry, where they were pioneered by Toyota Motor Corporation, which is viewed as the leader in utilizing these performance improvement methods. Lean has already enjoyed tremendous success in improving quality and efficiency in both the manufacturing and the service sector industries. RESULTSHealth care systems have just begun to utilize lean methods, with reports of improvements just beginning to appear in the literature. We describe some of the basic philosophy and principles of lean production methods and how these concepts can be applied in the health care environment. We describe some of the early success stories and ongoing endeavors of lean production in various health care organizations. We believe the hospital is an ideal setting for use of the lean production method, which could significantly affect how health care is delivered to patients. CONCLUSIONSWe conclude by discussing some of the potential challenges in introducing and implementing lean production methods in the health care environment. Lean production is a novel approach to delivering high-quality and efficient care to patients, and we believe that the health care sector can anticipate the same high level of success that the manufacturing and service industries have achieved using this approach. Hospitalists are primed to take action in delivering care of greater quality with more efficiency by applying these new principles in the hospital setting. Journal of Hospital Medicine 2006;1:191-199. © 2006 Society of Hospital Medicine.