The U.S. has the most expensive healthcare system in the world, yet “experts agree that it is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste, and fraud.”1
Clearly, no miracle cure will fix the mess. But perhaps some solutions are hidden in plain sight within organizations that have successfully cut waste, streamlined processes, and become more competitive and prosperous by integrating lean management systems.
What We Know
This isn’t because healthcare workers are inept or uncaring. They, too, are often victims of systemic inefficiencies and of complex and ambiguous processes. While some estimates place waste in healthcare between 30 and 40 percent, “the reality of what we’ve observed doing minute-by-minute observation over the last three years is closer to 60 percent,” says Cindy Jimmerson, founder of Lean Healthcare West.4 In fact, when one director of process improvement tracked nurses on a typical shift, he found they typically travel over five miles, much of it in wasted motion.5
American manufacturing has been fighting waste in all its forms for several years. Popular tools for doing so include the Toyota Production System (TPS) and Motorola’s Six Sigma. As a result, American manufacturing, once in decline, is experiencing a remarkable renaissance as a leader on the world stage.
Does healthcare have anything to learn from manufacturing? Might TPS, the lean practice that has been so successful for many companies, apply to healthcare, too?
Absolutely, say those who have experienced life on both sides of the fence, in manufacturing and in healthcare. Furthermore, several pioneering healthcare organizations have adopted lean production systems, and now, several years into the transition, are reaping the same benefits that transformed American manufacturing.
What lean means
The concept of lean manufacturing has trickled into public consciousness as catchphrases about eliminating waste and cutting cost. While that’s part of the picture, TPS is more substantial than buzzwords and more comprehensive than a weekend workshop. It requires an organization-wide commitment to analyzing work processes in order to systematically and continually improve them. Lean requires the participation of every individual in the organization, from the line worker (or the CNA) to the CEO. It isn’t easy to incorporate, and it isn’t a quick fix, but it can be incredibly effective.
The basic approach of TPS is to first understand the needs of the customer, then “go and see” every step of a process, whether it’s admitting a patient to the ER or installing a dashboard in a car, to determine whether it adds value in the customer’s eyes or is waste. Ambiguity is removed from processes by clarifying who is responsible for each task and exactly how and when that task will be performed. As problems are uncovered or better ways to complete the task are identified, they are addressed immediately with quick experiments to test the change. In that way, flexibility is built into fixed processes, and “root problems” are uncovered and corrected before they become embedded in the system.
Ideally, work flows smoothly (rather than in batches) along the simplest, most direct route and is performed the same way every time. Work is “pulled” through the line according to customer demand. And it is evaluated continually to improve the process.
All this is well and good for manufacturing, but how does it apply to healthcare? Caring for sick people isn’t like building a car. Or is it?
Lean for Healthcare
“Without question. The issues and problems are similar and can be addressed with similar processes,” says Steve Palmreuter, performance improvement coordinator, St. Mary’s Healthcare in Grand Rapids, Michigan. After implementing TPS at Herman Miller for many years, Palmreuter sought to bring those same processes to a major healthcare system in his local community. “The potential I see here for healthcare is tremendous,” he says.
According to Dr. Steven Spear, professor at Harvard Business School, the problem in healthcare arises when extremely complex processes are swathed in ambiguity about who is responsible for what tasks and exactly when and how they should be performed. Thus, opportunity for error is high, and there is no systematic way to address problems. “As a result, people confront ‘the same problem, every day, for years’ (as one nurse framed it for me) regularly manifested as inefficiencies and irritations—and, occasionally, as catastrophes.”6 As in other industries, employees become adept at working around problems rather than at solving them.
It doesn’t have to be this way. The stories emerging from healthcare organizations that have adopted lean practices point to striking improvements in patient care, elimination of waste and inefficiency, and the associated impact on cost. For example, central-line catheters that are placed in veins leading to the heart may speed the delivery of medication, but they can be deadly places for infection. Nationally, 250,000 patients contract central-line-associated bloodstream (CLAB) infections every year, and 15 percent of them die.7
At LifeCare hospital in Pennsylvania, the mortality rate for CLAB infections was 40 percent with cost per infection running between $25,000 and $80,000. By applying lean practices—removing ambiguity, quickly responding to problems, and testing process improvements, such as changing the disinfectant used—LifeCare reduced CLAB infections by 87 percent despite a 9.75 percent increase in lines placed. Other early adopters of lean healthcare practices, such as ThedaCare, Inc., in Appleton, Wisconsin, and the Virginia Mason Medical Center in Seattle, Washington, report similar improvements in patient care as well as annual savings in the millions of dollars.
Park Nicollet Health Services, a major medical center near Minneapolis, Minnesota, for example, reported saving nearly $7.5 million following its first year of top-down implementation of TPS—savings it passed along in lower fees for uninsured patients.8 Metrics like these require a commitment to change—both systemic cultural change as well as ongoing continual rapid experiments to test and improve processes.
While healthcare professionals are well-versed in experimentation and the scientific method, too often that training goes untapped in the top-down culture of healthcare organizations. “Nurses all have scientific degrees, so the concept of problem-solving ought to be familiar,” says Palmreuter, “but the culture interferes with problem solving. That’s a big challenge.”
“If you can get all of your people engaged all the time in making incremental improvements by using basic common sense tools, that’s very powerful,” says Ron Wince, CEO of Guidon Performance Solutions, a consulting firm that applies tools from industry to service organizations.9
Unfortunately, the crisis facing the healthcare industry is only beginning to play out. As the Baby Boom generation begins to stress the system beyond what it has ever absorbed, time to address serious systemic problems is growing short. “Making healthcare affordable today is difficult, but it will only be more challenging when America’s 78 million baby boomers start reaching retirement age in 2010 and place enormous demands on our healthcare system.” says David Wessner, CEO, Park Nicollet Health System.10 Lean isn’t the only solution, but it represents one solid and tested way to streamline processes, identify inefficiencies, reduce costs, and address systemic problems.
Although factories are different from hospitals, TPS offers the same potential to reduce waste, error, and unnecessary mortalities, to lower costs, to improve employee morale and retention, and to improve patient care. Realizing this potential presents at least two challenges. One is physical: How do you get the best alignment between the facility and the work people do there? The other is cultural: How do you get doctors, nurses, technicians, and everyone else involved to look at what they do in a new way?
Herman Miller, Inc., has experience with both challenges. Take the cultural aspect. It was an underperforming subsidiary that first led us to a meeting with Mr. Hajime Ohba, president of Toyota Supplier Support Center (TSSC), over 12 years ago. Soon after Mr. Ohba’s visit, we became one of only 200 companies in the U.S.—and the only office furniture manufacturer—chosen to participate in a special mentoring relationship with TSSC.
In the ensuing years, the problem subsidiary became Herman Miller’s best performer with the shortest lead-times and the highest margins. From 126 assembly employees running three shifts and struggling to produce 6,000 pedestal files a week, it now produces 8,000 units weekly with 22 people on two shifts in about half the space it occupied in 1996. “The turnaround of our facility was so significant that it got everyone’s attention,” says Matt Long, corporate director of continuous improvement, Herman Miller.
In 2000, the entire Herman Miller organization adopted the Toyota Production System as its sole management and manufacturing process. Toyota has designated Herman Miller a “showcase” company for TPS, and we regularly host other companies, including major healthcare organizations such as Mayo Clinic, that come to observe lean manufacturing in action.
A design perspective on lean environments
Park Nicollet Health Services, which includes a 426-bed hospital, a 25-location network of clinics, an institute, a foundation, and some 8,200 employees, began implementing TPS in 2004. The initiative is ongoing as every department continues to systematically analyze its processes—charting the paths patients follow, timing how long they wait and the route caregivers follow—in order to eradicate redundancy and waste. The Endoscopy Department, for example, implemented a “waterfall” patient schedule to create a steady flow rather than scheduling patients in 15-minute batches. Lights outside exam rooms indicate when patients are ready to move to the next stage—providing a visual cue to “pull” patients through the system. A more efficient way to restock supplies was designed.