Lean thinking helps hospitals improve quality of care, patient safety, and employee satisfaction by reducing waste. Applying Lean principles like standardizing processes and reducing unnecessary walking can double the time nurses spend with patients from around 30% to over 50%. Case studies show Lean initiatives in hospitals have significantly reduced infection rates, medical errors, costs from complications, and turnover while improving productivity and staff morale.

1. “How Lean Thinking Helps Hospitals”
Mark Graban
Senior Fellow, Lean Enterprise Institute
Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”

2. ?
?

3. St. Elisabeth Hospital: The Netherlands
Dr. Jacob Caron, Orthopedic Surgeon
Chairman of the medical staff

4. Henry Ford - 1922
“In the ordinary hospital the nurses must make useless
steps. More of their time is spent in walking than in
caring for the patient.”
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5. Fast Forward to 2005-2008
What % of time do “med/surg” unit RNs spend
directly with patients?
A: 21%
B: 33%
C: 50%
D: 65%
New Zealand: 33%
VMMC: 32%
UK: 34%
Illinois: 31%
Cinci Children’s 29%
It is possible to double this time with patients
More time to do the “right things”
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6. 6
• Deliveries of supplies delayed because of improper ordering
• Articles returned by other departmentsbecause they were not
made correctly
• Employees have difficultyin handlingnew-type equipment
• Limitedstorage space (linen and supplies) not properly used
• Safety equipmentnot being used
• Correct procedures not followed
• Employees leave to go to other hospitals

7. 77
*Warning: requires
effort and leadership
(not a silver bullet)

8. The Iceberg of Lean
8
Culture
Management System
Philosophy
5S
Kaizen
StdWork Heijunka
VSMs A3
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9. Pitfall – Focus on Implementing
Tools
"We were offering suggestions and getting pushback on safe staffing,
yet being told to reduce the number of pens and pencils.”
– RN (Minnesota)

10. Continuous
Improvement
Respect For
People
“Equally Important Pillars”
Eliminate
Waste
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11. Identify Causes of Walking
(Primary Care)
• MDs, PA, RNS:
– Poor organization
– Supplies in inconvenient
locations
– Missing information
• The system causes this
670 ft for single procedure prep
(pre-Lean walking pattern)
Exam
Procedure
Lab

12. Reducing Podiatrist Walking
• Created standardized cart
• Along with standardized rooms,
eliminated the need to leave the room
during patient encounters
Restocking Checklist

13. Quality and Cost
• “Lean is a quality initiative, it isn’t a cost-cutting
initiative. But the end result is, if you improve your
quality, costs will go down.”
– Bill Douglas, CFO of Riverside Medical Center (IL)
• Allegheny Medical Center:
– Reduced central line infections by 95%
– Hospital lost $26,839 per case (~16 cases/yr) = ~$500k/year
• Beth Israel Deaconess Medical Center:
– Avoided 300 V.A.P. cases in one year
– $12M cost savings

14. • 90% reduction in CR-BSI in MICU and Oncology
• Saved $1.7M
• Saved 17 days L.O.S. per case 14
Source: Dr. Richard Shannon

15. ThedaCare Coronary Bypass
Improvement
12
1

16. Case Example: MRI Suite

17. Reducing MRI Waiting Time
0
2
4
6
8
10
12
14
Weekswaitingforappt
Outpatient Radiology Backlog
Source: Children’s Medical Center, Dallas TX

18. Typical Department Silos
Oncology Clinic A
Oncology Clinic B
Oncology Clinic C
Chemotherapy
Treatment
Radiation
Treatment

19. Patients Scheduled 5/2/06
0
2
4
6
8
10
12
14
16
18
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
Start running
out of chairs
Idle Time
Oncologist Schedule
Look Across the Value Stream -
Oncology

20. ThedaCare Code STEMI
• Starting Point 2002
– “Did not have a clear,
standardized response to
heart attacks.”
• Studied each process step
in detail
• Posted standardized work
in each room

21. ThedaCare “Door to Balloon” Time
91
65
52
37
0
10
20
30
40
50
60
70
80
90
100
2005 2006 2007 2008
Minutes
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22. Need to Stop Blaming People
"[The CEO] said the
technician responsible for
the mix up also no longer
works there."

23. A Different Hospital Lab…
“It’s OK,
my people
are very
careful!”
3 Different Patients - Batched

24. Toyota’s Chairman
Mr. Cho
• Go See
– “Senior Management must
spend time on the front lines.”
• Ask Why
– “Use the “Why?” technique daily.”
• Show Respect
– “Respect your people.”
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Three Keys to Lean Leadership

25. “Gemba”
“Toyota managers
should be sufficiently
engaged on the
factory floor that they
have to wash their
hands at least
three times a day.”
Taiichi Ohno
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26. “…Kaplan tours the
hospital daily looking
for problems and
solutions. Everyone is
encouraged to look for
changes to make work
more efficient.”
- Virginia Mason CEO Gary Kaplan
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“Gemba is for Everyone”

27. Patients
(Gemba)
Walkway over
tracks
Executive
Offices
Parking
Garage
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28. “Convis became the first
North American to head a
Toyota manufacturing plant
when he was put in charge
of the Georgetown facility.
He responded to the
promotion by moving his
office from the admin
building adjacent to the
Georgetown plant to the
center of the factory floor.”
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29. Six
Sigma
Adapted from: “The Toyota” Way Fieldbook, Liker and Meier
Very few
Large problems
Few
Medium problems
Many
Small problems
Mgmt
Kaizen
Kaizen
Event
Daily Kaizen
Different Types of Kaizen

30. Chemistry: Before
Chemistry: After
CA
Core Manual
Lab Layout: Before & After

31. Metric Before After
Potassium IP TAT 74 min (June ’06 avg)
43 min (May 07 avg)
42% reduction
Labor Productivity 0.14 WHPUOS
0.12 WHPUOS
14% reduction
% of Results on
Chart < 7 AM
62% 92%
Square Footage
228 sq ft freed up
(behind manual area, to side of
special chemistry)
Initial Improvement

32. Lab Improvement (3 years)
32
30
35
40
45
50
55
60
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
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Oct-07
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Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Troponin TAT (in minutes)

33. Lab Improvement (3 years)
33
75%
80%
85%
90%
95%
100%
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
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Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
% tests by 7 AM

34. Lab Improvement (3 years)
34
0.100
0.110
0.120
0.130
0.140
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
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Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Labor Productivity
(Worked Hours per Unit of Service)

35. The Problem with Ignoring
“Respect for Humanity”
Found posted in a hospital lab
(during Lean assessment)

36. Engaging Employees
From Locked Box To Visual Idea System

37. One Idea Card Format
FRONT BACK

38. Documenting & Celebrating
Improvements
• What was the problem?
• What was changed,
improved, or
implemented?
• What were the benefits?
• Who was involved?
Kaizen Wall
of Fame
What was the Problem?
For disposal of pipette tips, the only containers we had were “sharps” containers. This
Adds extra disposal cost, as the tips are not sharp. The container hole was also
Hard to get tips into.
What was changed, improved, implemented?
Create biohazard bag holders out of urine jugs, cut the tops off.
Photo/Diagram:
What were the benefits? Safety? Quality? Time? Waste? Cost?
Reduces cost since we aren’t doing unneeded sharps disposal and we aren’t throwing
the containers away each time. No safety risk.
Easier to get tips into container (less motion and less arm strain, since the
Container is lower and easier to get into). Tips can be dumped into a larger
Biohazard bin or we can replace the bag.
Who was Involved?
Gretchen, Beth, Janie, Franke
Date:
5/31/07
Area:
STL
Old Style
Container
New
Container

39. Kaizen Wall of Fame – Core Lab

40. Value of Kaizen in a Hospital?
• $4,000 per employee (Toyota)
– Just the quantifiable benefit
• What about benefits from:
– Better Quality
– Morale
– Patient Satisfaction
– Less Waiting Time
= $$ ?

41. Employee Quote
“This is the best thing
we’ve done in my 20
years. We’re finally
fixing things.”

42. Data From Children’s Medical
Center Dallas
Before Lean 12 Months
After Starting
3. I have the opportunity to do what I do
best every day.
3.11 3.92
8. I feel free to make suggestions for
improvement.
2.84 3.48
10. I feel secure in my job. 2.32 3.42
13. Stress at work is manageable. 2.43 3.23
17. I am satisfied with the lab as a place to
work.
2.51 3.43
18. I would recommend my work area as a
good place to work to others.
2.38 3.46
Grand Average 2.96 3.69

43. Lean Benefits All Stakeholders
Patients
Caregivers
• Employees
• Medical Staff
• Administrators
Hospital
• Safety & Quality
• Caring Encounters
• Less Waiting and Delay
• Mission
• Stewardship
• Stability / Growth
• Pride in work
• Less frustration
• Job security
• Career growth Philosophy
People
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44. Q&A
• Email: mgraban@lean.org
• Lean Enterprise Institute: www.lean.org
• Healthcare Value Leaders: www.hcvln.org
• Blog:
– www.leanblog.org
• Twitter:
– www.twitter.com/LeanBlog
– www.twitter.com/HCVLN
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