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Saturday, December 2, 2017

Toyota Healthcare: 7+1 Types of Waste

Lean thinking as defined by Lean Enterprise Institute is a set of concepts, strategies, principles, values and tools used to create and deliver the most value from the customer perspective while consuming the fewest resources and fully utilizing the knowledge and skills of people performing the work. If you visit Toyota assembly plants you can see how Toyota has put all the systems and supports staff in place to ensure that the production team members on the assembly line always have the parts and necessary tools they need to do their jobs. Trucks are not as important as patients, but Toyota arguably puts far more effort into supporting their front-line staff than many hospitals do. Toyota allows the team members to focus on their work and the truck in front of them, leading to better results and satisfaction for all. 

Going back into history
In 1926 Sakichi Toyoda invented the automatic loom system. He is considered the father of the Japanese industrial revolution and has been given the title of "king of inventors." Sakichi has set his own values that eventually became the guiding principles of Toyota Motor Company (contribute to society, get your hands dirty, respect for people, put customer first....). Built in quality was most evident in one of his most influential inventions- the loom that could stop itself when there is a problem. He called this jidoka. His son Kiichiro created the automobile company Toyoda. Kiichiro is a mechanical engineer, he created "just-in-time" JIT principle. Later, Taiichi Ohno developed a new manufacturing system turning just-in-time from a concept to a working system. Ohno methodology was endless kaizen. Ohno is the owner of idea cellular production and takt time. Kiichiro Toyoda's just-in-time and Sakichi Toyoda's jidoka are the two key pillars of Toyota Production System TPS.
Lean is inspired by TPS. In The Toyota Way to Service Excellent Jeff K Likershowed us how lean is widely applied for service organizations. Some of the best examples we can see of lean in services are kicked off by visits to exceptional lean factories. One of the best in healthcare is ThedaCare in Appleton, Wisconsin. John Toussaint, CEO at the time, had an epiphany after he visited a manufacturer of snowblowers whose president was totally committed to lean. During the visit Toussaint saw engaged people and a true flow of value through the factory. Certainly this factory was at least as complex as his healthcare systems! He could easily imagine a healthcare system where patients did not queue up and wait, but were flowing through the healthcare experience without interruptions. He also learned that he needed to lead the transformation from the front. As his organizations learned and evolved, patient waiting time reduced dramatically. A new way of thinking led to many changes in the process include how and where blood samples were analyzed. In the past lab work was centralized and could take days. Now most tests are completed in on-site clinics in minutes. In fact, after years of improvement, about 90% of lab tests or imaging studies needed in primary care can be completed on-site, and 95% of the patients leave with a plan of care in a single visit.
What is lean healthcare?
As defined by Mark Garban in Lean Hospitals, lean healthcare means delivering the most value to patients while consuming the least resources and maximizing the use of people skills and knowledge. Lean healthcare strives to improve quality, mistake-proof errors, improve patient safety, and increase value added through the removal of the wastes and defects possibilities. We say defects possibilities because in certain areas defects aren’t allowed to happen as they can be catastrophic, threat life’s and directly affect patient safety. In manufacturing, a defected product will cost three times more than doing it right first-time following jidoka principle. Re working a defected part add more costs and delay product to customers. In healthcare, defects or mistakes can lead to improper sterilization, wrong drug prescription, incorrect drug dosage, or improper diagnosis which can lead to health hazards.
Manufacturing organizations try to motivate their employees to improve the system and engage the front-line workers by explaining how lean can make their work easier and safer. They usually mention profitability and indirect financial gains. In healthcare, people who do the work are intrinsically motivated by the desire to help people. A desire that led so many to healthcare. Engaging them in lean thinking to improve the system for patient safety and saving life’s can be much easier. Lean can free time for healthcare professionals, so they can focus more on their basic work they learned to do in the college (providing the patient care) instead of spending their time solving daily problems. Lean leaders should make sure that this intrinsic motivation is not eroded overtime through frustration and burnout. Lean leaders should look at the system and process rather than blaming an individual.
How lean improves healthcare?
Lean doesn’t accelerate the value-added works. The traditional improvement habits involve improving performance by accelerating work, and running things faster. Conversely, lean works by taking out wastes and the non-value-added steps to improve the value-added processes. Improving the value-added work by making people work faster can result in overburdening people (muri) and unbalancing of work (mura) which will result in more mistakes and errors. It can create wastes in other linked areas.
Lean healthcare is not about cutting costs by reducing the level of service and the quality of care like what many governments do. Lean is about improving quality and adding more value and the financial gains will come at the end. Putting more value in patient care and improving quality are the keys for cost improvements.
Areas of improvements in healthcare centers and hospitals and how to tackle wastes
I receive all the time these questions about the applicability of lean for healthcare and hospital sectors: is lean applicable for department of radiology? What about the intensive care unit? Hospital warehouse? Is lean applicable for hospital pharmacy? The fact is that lean can apply in all places in hospitals and medical centers. There are numerous opportunities of improvements usually find in laboratories, clinics, diagnosis rooms, operating rooms, surgical rooms and intensive care units. E.g. Lab productivity can be increased by improving turnaround time. The time from drawing patient sample till delivering the results. A lot of labs use poor layouts that obstacle the flow of samples or use batch processing, so many samples will have to wait before being inspected and diagnosed. Avoid batch processing in laboratories and using one-piece flow saved many labs thousands of dollars and reduced the turnover time dramatically.
Garban in Lean Hospitals presented a simple case of improving laboratory turnaround time involved moving specimen collecting point in the lab closer to the diagnosis device helped a laboratory in reducing the turnaround time by 29%.
Another example of improvement is the turnaround time between surgeries in surgical rooms (quick changeover) which can be done following the Toyota approach single minute exchange of die SMED. Often the preparation for the next surgery is done in the downtime between surgeries. Instead, there should be a standardized work process to prepare the room for next surgery during
the current one and provide all necessary tools and instruments in place.

Nurses walking is another type of waste and is one of the most common issues in medical centers. Often this cause waiting wastes and delays service to patients. A value stream analysis can tackle areas of wastes. Some organizations use video cameras to monitor and record wastes, but employees should know they are monitored for process improvement. In some hospitals nurses use a pouch waist bag that include all necessary tools and instruments they need for daily use, so they don’t have to walk here and there to bring them.

The eight types wastes provide opportunities for improvement
TPS classifies processes into value added and non-value added. Any process that doesn’t add value to customer or customer is not willing to pay for it is considered non-value added and should be improved. In medical care, any process that doesn’t provide patient care is considered non-value added. For example, a doctor standing in the diagnosis room waiting for someone to bring a missing instrument is a non-value added that need to be eliminated. Some non-value-added steps can harm patients or cause a near miss.
TPS described eight types of wastes summarized below:
Defects: refers to not doing things right first time. Re working defects is one of the biggest wastes. Example, a wrong drug prescription or incorrect dosage can harm patients. Another example of process defect is storing the adults drug into the newborn intensive care unit. Defects doesn’t necessary have to cause harm to be waste. Defects include things that go wrong and need to re work. Radiology errors can lead to a patient's losing a chance for successful treatment. A problem in collecting a semen sample for sperm analysis can lead to wrong results. The failed collect attempt, time required to have collect the specimen, time spent in analyzing specimen in the lab are waste for both employees and patients.

Waste of talent: refers to under-utilization of human talent. A laboratory physician that draws specimen or load it on the diagnosis device is a waste of talent. He can help analyzing and troubleshooting the test results. Young assistants can do the job of loading specimens.

Nurses should spend their time charting with patients, talking to them about their health statement, describe how drug dosage should be administrated, and discuss with them their length of stay. Nurses time should only be spent in-patient care. Unfortunately, most of nurses spend their times walking between departments, bringing tools, searching for instruments and bringing drugs. Some activities that don’t require skills can be done by less expertise people to reduce the cost of the job.

Waiting: the most common waste in all hospitals and the most obvious one for patients because they directly experience it include: waiting when reserve doctor appointment, waiting once they arrived at clinics, waiting to pay bills, or waiting to discharge. Patients may not be the only ones that experience waiting, physicians, and doctors can wait to get the tools they need. Other forms of waiting wastes include waiting for pharmacy orders, waiting for medications to arrive or waiting to sterilize tools. Waiting waste delay care to patients.

Transportation: refers to the movement of product between different departments or sections. Transportation is greatly affected by the layout of hospitals. In an intensive care unit, the nurse average walking time per day was estimated between 7 to 9 kilometers. Layouts should be designed in a way that reduces transportation time for patients, specimens and hospital staff. Also consider that sick patients should not move long distances between buildings and different areas.
Motions: refers to ergonomics in workplaces. If tools, instruments, and other necessary parts aren’t handy, people will move here and there searching for them.

Overproduction: doing unnecessary tests and checkups is a waste. Over producing information that is not useful or won’t be used is a waste. It can delay patient treatment and add more cost to the service.

Inventory: in medical environments, there is always a tradeoff between keeping inventory at low level and the harmful results from running out of inventory. Lean encourages having the right supplies and inventory on hand to ensure the right patient care can be delivered on time. Hospitals should work with their suppliers to ensure the delivery of drugs on time and keep a safety stock for emergencies. A tool like Kanban can ensures the right supplies are provided with the right quantities on the right time in the right place.

Over processing: involve doing unnecessary steps in the process, or repeating steps. E.g. patients had to describe the symptoms several times to doctors during the follow-ups. Another example found in labs, sperm vitality test requires a use of a hypo osmotic swelling solution for the evaluation of the sperm membrane. Using more amount of the chemical solution than needed won’t make a different. Also, many labs found that the time sperms left in the solution is set at times longer than needed. Usually less than a minute is enough to show how many sperms are reacting and vital.

One of the most common reasons why over processing waste exists is the work standardization. No standardization will create many wastes.
Our own attitude that we are charged with discovering the best way of doing everything.
"Henry Ford"
Jimmerson in his book Value Stream Mapping for Healthcare Made Easy showed us how mapping the process can be used to tackle wastes in the process of patient treatment. The process of patient treatment starts from patient feeling symptoms till receiving care and end with paying bills. The process may include making the appointment to meet doctors, performing the required screenings and analysis, delivering results, receiving the actual treatment, and follow up until full cure.
Defects is the worst form of waste. Standardization is the foundation of quality and continuous improvement. In healthcare not having a standard or not following it can lead to miserable results. Eg. Inappropriate labeling specimens in fertility centers can lead to IVF mix-ups. Failure in the sterilization process can lead to lethal infections.

The following few question can quickly signify problems:
  • How many times a surgeon had to wait for tools or instruments?
  • How many times a patient had to repeat information to doctors?
  • How many times there has been wrong prescription of drugs? Or patient take wrong drugs/dosage because of unclear instructions or insufficient patient education?
  • How many times a patient had to wait for a room to be freed?
  • Average waiting time for patient to get serviced.
  • Turnover time of clinical laboratory (measured from patient requesting service till the time the laboratory deliver the results).
  • % of satisfied patients from quality of care service provided by the hospital.
  • % of nurse total work time spend in patient direct care.
  • % of times a wrong medication were delivered from pharmacy to clinic (include wrong drugs or incorrect quantities).
  • % of times a doctor had to re prescribe a diff medicine due to patient allergy or because drug was not efficient.
  • % of times a drug reached zero inventory in pharmacy and affected patients.
  • Inventory turnover % in hospital pharmacy.
  • % of value-added works.
  • Cost of re works as a % of total costs.
  • Percent of times hospital run out of supplies include laboratories, pharmacy, surgical rooms,…etc.
  • % of expired supplies that must be disposed of.
  • Total number of safety incidents in hospital.
  • % of late surgery starts or percent of on-time surgery starts.
  • % of late patient charges.
  • % number of critical/risky processes that are included in the failure/risk prevention techniques.
  • % of employee time spent in non-value added activities
  • Lab productivity %.
  • Operating/surgical room turnaround time (turnaround time between surgical cases).
  • % of critical/essential processes that has standard operating procedures (eg. Hand washing hygiene, preparation for surgery, labeling patient specimens).
So how do you see wastes in healthcare industry? Do you have experience in implementing the Toyota Way in healthcare? How was your success in engaging hospital staff and employees? How was the transformation results? The top management commitment to change? 
Next couple of articles I will go in deep into the lean transformation for healthcare organizations and and how to eliminate the wastes. I will discuss the importance of standardization in healthcare as foundation of quality as well as the most common lean tools used in healthcare with some real case studies from my experience in fertility centers.
If you liked the article, please share it using one of the social media sharing buttons below! And feel free to share it on LinkedIn too!


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