What Is Lean Healthcare? Methodologies & Implementation

Lean is not a rigid or short-term set of standards; thus, its adaptability and iterative nature make it a valuable strategy for both product- and process-focused industries. In other words, Lean can be applied to organizations that revolve around repeatable assembly-line production or more service-focused work — like a hospital or healthcare system.

The Virginia Mason Institute defines Lean healthcare as:

• Promoting a culture of continuous improvement.
• Implementing processes that add value to the patient’s experience, and eliminating those that do not.
• Aligning leaders and staff around a shared vision.
• Empowering frontline staff to drive improvement efforts while respecting their expertise as the individuals who do the work.
• An organization’s willingness to change by identifying the root cause of problems and making corrections to improve processes.

Training Within Industry (TWI) instruction for healthcare often incorporates Lean tactics.

When first introduced to the concept of Lean healthcare, many people might object that “patients are not products!” While this is true, it should be noted that a Lean approach to identifying waste and variation is evidence-based — much like a doctor’s approach to diagnosing and treating a patient. While the “end results” of manufacturing vs. healthcare are fundamentally different, they can be achieved using the same methods.

Just like in any other industry, the primary goal of Lean healthcare is identifying and reducing waste and defects. Defects can manifest in healthcare in ways large and small, inconvenient or dire: excess supplies, overworked staff, overmedicated patients or high infection rates. A healthcare provider’s first duty is to do no harm, but poorly designed processes make delivering on that promise challenging. That’s where Lean comes in.

All members of a healthcare organization must participate in system-wide improvement — from the facility’s chief medical officer, to the shift nurses, to the internal medicine specialists, to the ambulance drivers and the front desk receptionists. Lean healthcare works when all hands are on deck to identify anything that does not add value to the patient experience; sometimes even the patients themselves are involved in this process!

A Lean approach to healthcare can eliminate all aspects of an organization’s processes that don’t result in, or contribute to, high-quality patient care. This leads to better overall population health.

Using Lean management principles, hospitals can:

• Increase patient satisfaction
• Drive down infection rates
• Improve scheduling
• Decrease wait times
• Decrease overtime work
• Streamline paperwork processing
• Increase clinic revenues
• Optimize existing resources to treat more patients
• Improve staff experience, stress levels and job satisfaction

On a more granular level, Lean-informed TWI instruction teaches managers and frontline healthcare workers how to:

• Create stability, standardize their processes and use them as a baseline for continuous improvement.
• Practice using a scientific approach to identifying issues that distract them from caring for patients.
• Use a visual planning process to establish key objectives for the organization, such as a whiteboard or slide deck.
• Conduct structured and productive dialogues across all levels of the organization.

While the first priority for any healthcare organization is the care and satisfaction of its patients, Lean methodology can also help lower costs and reallocate capital as necessary. Through eliminating wasted inventory, time and talent, hospitals can save money while still delivering on objectives and patient expectations.

Lean methodology identifies eight wastes present in every industry. Taiichi Ohno, father of the Toyota Production System (TPS) and inspiration for Lean methodology, established seven initial wastes; an eighth (non-utilized talent) was later added to the TPS.

The eight wastes of Lean (often referenced using the acronym DOWNTIME) are:

• Defects
• Overproduction
• Waiting
• Non-utilized talent
• Transportation excess
• Inventory excess
• Motion excess
• Excess processing

In Lean healthcare, the eight wastes can be addressed thus:

• Defects: Train staff in eradicating care-related defects (such as infections, incorrect medications and blood clots) to improve the quality of care and increase reimbursement.
• Overproduction: Extended hospital stays and duplicate tests can be eradicated to save resources.
• Waiting: Minimize patients’ wait time, doctors idling or standing by and delays caused by late arrivals (of patients, staff or supplies).
• Non-utilized talent: Any of these sources of waste can use up a staff’s valuable time and talents, which might be better spent building relationships with patients, pursuing continuing education or supporting departments in need.
• Transportation excess: Reduce the transport of patients and supplies by optimizing access to services, equipment and specialists.
• Inventory excess: Only stock the supplies, medications and equipment you need in order to free up storage space and capital.
• Motion excess: Prevent injuries and save critical time by reducing staff and patient movement throughout the facility.
• Excess processing: Duplicate modes of data entry, such as patient forms and test results, can be streamlined into one easily-accessible platform.

As part of a Lean approach to work, every member of a healthcare organization learns to ask, “Does this add value for the patient?” If it doesn’t, it most likely falls into one of these categories of waste.

Like Lean, Six Sigma is a management strategy aimed at reducing errors and removing defects from processes. However, Six Sigma is driven by metrics in a way that Lean is not — which does not always translate well to healthcare.

Six Sigma aims to decrease defects in 99.99966% of all outcomes. This methodology is frequently applied in manufacturing settings, where process standardization can aid predictability. While there are many aspects of healthcare that can be standardized, the treatment of (sometimes volatile) patient populations is inherently unpredictable and requires flexibility.

Elements of Six Sigma are sometimes incorporated into a Lean healthcare strategy; for example, the DMAIC method (Define, Measure, Analyze, Improve, Control) can be applied to an existing process like patient check-in. See the example below.

However, official Six Sigma implementation requires costly training, access to proprietary platforms and intensive analytical assessment. Lean is largely favored in healthcare for its malleability, as well as its capacity to include all members of a care team in identifying areas for continuous improvement and taking appropriate action.

Jim Womack and Dan Jones, the founders of the Lean movement, recommend that organizational leaders focus on three areas of improvement when building a Lean strategy:

• Purpose: What is your organization’s ultimate goal? This is usually encapsulated in your mission statement.
• Process: Evaluate each step of every procedure to ensure it adds value, makes sense, does not waste resources and can be adapted if necessary.
• People: Your people are your organization’s most important asset. Is each person being used in a way that leverages their talents? Is each team member empowered to identify areas for improvement in your processes?

First and foremost, the success of a Lean approach to healthcare requires buy-in from every member of an organization’s team. Without all members’ participation — especially the leadership at the top — strategic implementation of Lean principles won’t work.

Some leaders of a healthcare organization may object to a TWI or Lean approach simply because the training methods are not highly technical. Lean methodology promotes a visual approach to making changes, so that workers and leadership at all levels can see where improvements might be made.

“It’s old school pen and paper; you’re writing on a whiteboard, you’re using a stopwatch,” explains Martha Purrier, Director of the Kaizen Promotion Office at Virginia Mason Medical Center and co-author of Getting to Standard Work in Healthcare. “There may be a time in your Lean adventure where you build things like electronic medical record order sets, or registration [software]. But the real journey is done by hand first — so someone who wants to automate [processes] at the speed of light…will just look for [a different solution], something they can buy, implement and move on to the next problem. None of the TWI or Lean work is like that.”

The field of healthcare incorporates both hard data and relationships, but those in Human Resources or Information Technology may struggle to see the value of an improvement strategy that favors iteration and old-fashioned brainstorming. This is where TWI instruction can help bridge that gap in understanding.

“The thing about TWI is it creates relationships between your employees,” says Judy Mann, a TWI Certified Trainer and Registered Nurse. “It’s not just [focusing on] the technical, clinical parts.” Mann says that organizations who follow TWI instruction in implementing Lean in healthcare can measure outcomes by employee satisfaction and retention, which satisfies leadership concerned with the bottom line.

“How do you, as a company, come across as the whole package?” Mann asks, referring to healthcare organizations trying to attract a motivated workforce. She recommends that organizations that use TWI instruction promote the people-focused aspects of their training programs to attract passionate healthcare professionals.

Considering its history of frontline worker training dating to World War II production lines, most people moderately familiar with TWI (which inspired the Toyota Production System and, therefore, Lean) may think it only applies to technical Job Instruction (JI). Skip Steward, Vice President and Chief Improvement Officer at Baptist Memorial Health Care, hopes that his organization’s success with TWI instruction will be an example of how other aspects of the training can apply to healthcare.

“One of the challenges of TWI is that people don’t really get super excited about it until they get their hands dirty with it,” says Steward, who experienced the Job Relations (JR) and Job Methods (JM) portions of TWI instruction first hand. “But as soon as people play with it, they’re like — oh, my goodness, where has this been?”

Steward considers TWI JR an “amazing secret” that gives frontline supervisors practical tools with which to respond to personnel issues. This access to a defined set of skills is crucial in a healthcare setting, where communication is key to keeping patients safe and healthy.

In 2002, Virginia Mason Medical Centers began adopting Lean strategies inspired by a visit to the Toyota Motor Company in Japan. Virginia Mason is the first healthcare organization to implement TPS strategies across its entire system, and used this foundation to build its own continuous improvement system. The Virginia Mason Production System (VMPS) is now taught at the Virginia Mason Institute.

As Gary S. Kaplan, CEO of Virginia Mason Health System puts it, the goals of implementing a change like this should be:

• To create a sense of urgency around improvement
• To develop a shared vision for the present and future
• To align expectations across departments
• To demonstrate visible and committed leadership

Certified coaches can help healthcare teams learn the skills needed to achieve these goals, but any system-wide adoption of new skills must be nurtured and sustained by team leaders and frontline supervisors. If they are unfamiliar with frontline processes, upper-level managers need to spend time at the front line of healthcare understanding the issues, learning to eliminate obstacles, challenging teams to share ideas and coaching problem solving.

TWI instruction teaches managers to lead by asking questions rather than giving hardline directions, which in turn helps frontline workers learn by doing. The resulting sense of agency felt by healthcare workers translates directly to tangible patient outcomes — proof that a Lean approach to healthcare prioritizes people above all else.

For more information about how TWI and Lean can net more positive outcomes for your healthcare organization, start a conversation with TWI Institute today.