What Is Lean Healthcare?

This article appeared in NEJM Catalyst prior to the launch of the NEJM Catalyst Innovations in Care Delivery journal. Learn more.

Lean healthcare is the application of “lean” ideas in healthcare facilities to minimize waste in every process, procedure, and task through an ongoing system of improvement. Using lean principles, all members of the organization, from clinicians to operations and administration staff, continually strive to identify areas of waste and eliminate anything that does not add value for patients.

To find new solutions to the unsustainable 5.5% per year projected growth in national health expenditures, members of the healthcare industry have been applying the Principles of Lean Manufacturing to help rein in costs and add value for patients. One area of focus is increasing “customer” (patients and payers) satisfaction and doing so profitably. Because eliminating waste at every level of an organization is fundamental to lean principles, and because “lean thinking” requires buy-in from every member of an organization’s team to be successful, it becomes deeply embedded in the culture, resulting in innovation at every level. By deploying lean healthcare, organizations are also improving patient satisfaction as decisions and processes become more and more patient-focused.

Lean Six Sigma in Healthcare

Although sometimes confused, Lean and Six Sigma are often used in tandem in healthcare and other industries to create improvements, but they go about it in different ways. Six Sigma is a metrics-driven system used to reduce medical errors and remove defects from processes involved in delivering care. Both methodologies strive to optimize operations and increase value for patients. However, while Lean focuses on eliminating waste, Six Sigma seeks to reduce variation by decreasing defects to a specific statistical measure. In the last two decades, the two systems have been combined into the hybrid improvement process called “Lean Six Sigma.”

Organizations who are instituting lean principles in healthcare, like Virginia Mason, creators of the Virginia Mason Production System (VMPS), make the case that Lean is the better overall approach for improvement in healthcare because it values all members of the patient care team and can be implemented by anyone. Unlike Six Sigma, Lean does not require advanced statistical methods, costly training, or expensive platforms and systems. More importantly, lean values can be applied incrementally on a continual journey toward value-based healthcare. Each care episode and every patient interaction represent opportunities for cultivating value and cutting waste.

Lean Methodology in Healthcare — Cut out the “Eight Wastes”

Taiichi Ohno of Toyota, the originator of lean principles, described seven areas of waste that occur in every industry. (Toyota later identified the eighth waste.) It may seem counter-intuitive to apply what has worked in manufacturing in a hospital setting, but by implementing lean in healthcare and reviewing processes and systems through the lens of the eight wastes, organizations can potentially:

1. Reduce Waiting / Idle TimeAccording to lean principles, any time patients or employees are required to stand by, waste happens. Patients sitting in waiting areas, meetings stalled for latecomers, appointment waiting lists, and idle high-tech equipment are all areas that represent opportunities for healthcare organizations to tap the creativity and imagination of their teams to reduce waste.

2.  Minimize InventoryInventory represents tied-up capital and storage cost. Surplus supplies and medications, superfluous equipment, extraneous data, or stockpiles of pre-printed forms all translate to inventory waste. Moreover, excessive inventory increases the risk of loss from being stolen or becoming obsolete. Employees throughout the organization can be trained to recognize excessive inventory and find novel ways to decrease it.

3. Eradicate Defects to Improve Quality of Care and Increase Reimbursement Process or system failures, medical mistakes, and misdiagnosis are examples of defect waste in healthcare. Healthcare-acquired conditions such as blood clots and infections, medication or surgical errors, avoidable readmissions, preventable allergic reactions, incomplete or erroneous medical records all illustrate defect waste in healthcare. As payers move toward pay for performance models that reward/penalize outcomes, organizations can leverage lean principles to mobilize every employee to eradicate defect waste and improve quality to positively impact the bottom line and, most importantly, to avoid mistakes.

4.  Transportation – Decrease the Movement of Patients, Supplies, and Equipment to Improve Patient Flow Transportation waste in healthcare involves moving people, supplies, and medical equipment unnecessarily. Transporting patients to different departments and running around to gather supplies also increase the risk of patient or caregiver injury (defect waste) and create delays in care (waiting waste). Lean thinking can be used to analyze patient and caregiver movement through the hospital facility to save time, reduce injury, and improve patient flow.

5.  Prevent Injuries and Save Time by Reducing MotionWaste in motion occurs whenever hospital workers perform movement within their workspace that does not add value for patients. Reaching or stooping for frequently used supplies and equipment, increased walking due to poor building design, or non-ergonomic patient transfers between beds, wheelchairs, or operating tables are potential instances of motion waste.

6. Maximize Resources by Minimizing Healthcare OverproductionOverproduction waste entails redundancies, creating too much of something, or creating it at inappropriate times. Preparing medications for a discharged patient, duplication of tests, or extending hospital stays beyond medical necessity are all examples of overproduction that healthcare organizations can tackle.

7. Remove Waste from Over-ProcessingOver-processing occurs when unnecessary work goes into treating patients. Needless tests, filling out different forms with the same information, and performing data entry in more than one system are examples. When time, effort, and resources do not add to the quality of care or improve patient outcomes, it has the potential to be changed or eliminated through lean analysis. By viewing all processes through the lens of lean healthcare, staff can help identify repetitive, redundant, or less than valuable processes to save time and money.

8. Understand how Healthcare Waste Leads to Untapped Human Potential – the Pinnacle of Waste in Healthcare When workers’ time is consumed by any of the above, they are unable to use it to leverage their creativity and talents for work that promotes patient care and optimized operations. Waste in healthcare detracts from time that employees could use for educational pursuits, building relationships with patients, or implementing systems-based improvements. Adopting a lean culture not only leads to improvements in care quality and decreased cost, it also leads to improved employee morale and commitment.

Figure 1 .

Lean Healthcare 8 Wastes: Waiting/Inventory/Defects/Transport/Motion, Overproduction/Over-Processing/Untapped Human Potential

Lean Healthcare Examples

Improving patient satisfaction, scheduling appointments, decreasing overtime work, processing paperwork, and increasing clinic revenues are just a few of the areas where hospitals and other healthcare facilities are implementing lean principles. Some interesting lean healthcare examples are highlighted here:

• Redesigned Patient Rooms At ThedaCare, supplies, medications, and electronic-record-keeping systems were relocated into patient rooms which allowed nurses to spend 70% more of their time with patients. Additionally, patient safety was improved by equipping rooms with ceiling lifts, beds with alarms and scales, and other equipment.

• Crash Cart Inspections Nicklaus Children’s Hospital reduced crash cart inspection times from three hours to ten minutes through visual optimization and the reduction of excess supplies and equipment.

• Lean Scheduling — Dyad Mother/Newborn Appointments for Postpartum Care Denver Health’s Eastside Clinic experienced a large number of no-shows for maternal postpartum checkups due to transportation barriers and long appointment wait times. To solve this dilemma and to promote patient-centered care, the clinic combined the mother’s and infant’s appointments into one. The result was a decrease of no-shows from more than 50% to just 15%.

• Patient Safety Alert (PSA) System One of the numerous initiatives at Virginia Mason is their Patient Safety Alert (PSA) System through which all staff are to report possible patient safety issues. Reported concerns are quickly investigated, and interventions are promptly implemented. Because of this system, liability claims at Virginia Mason decreased by 74% from 2005 to 2015.

Implementing Lean Principles in Healthcare

Since the first pioneers shared their learnings at the Global Lean Healthcare Summit in 2007, more and more healthcare organizations have implemented lean methods in their mission to gain control over costs while improving care quality and outcomes. Applying concepts developed in manufacturing to healthcare has called for a thoughtful approach for adapting these innovations to the hospital setting.

When applying lean principles in healthcare, organizations leverage a set of tools for implementing change. The focus becomes the elimination of steps and processes that do not contribute to patient satisfaction and superior care. Healthcare leaders appreciate the perspectives of front-line clinicians for providing new insights. Everyone in the organization learns to ask, “Does this add value for the patient?” According to Gary Kaplan, CEO of Virginia Mason Health System, implementing change requires leaders to go beyond lean and to create a “sense of urgency,” develop a “shared vision,” “align expectations,” and demonstrate “visible and committed leadership.” In this way, organizations are using lean to effectively harness the collective intellectual capital of all their team members to maximize value for patients and to decelerate the unsustainable cost trajectory of healthcare.