This Sunday, the New York Times had an interesting article on applying lean operations to health care (Factory Efficiency Comes to the Hospital, Jul 11). The story focuses on Seattle Children’s Hospital and the examples range from managing inventory to improving patient flow:
On a busy day last month in the I.C.U., it took [nurse Susanne] Matthews just a few seconds to find the specialized tubing she needed to deliver medicine to an infant recovering from heart surgery. The tubing was nearby, in a fully stocked rack, thanks to a new supply system instituted by the hospital early last year following practices typically used in manufacturing or retailing, not health care.
There are two bins of each item; when one bin is empty, the second is pulled forward. Empty bins go to the central supply office and the bar codes are scanned to generate a new order. The hospital storeroom is now half its original size, and fewer supplies are discarded for exceeding their expiration dates.
So that sounds just like a kanban system; it limits the amount of work-in-process that can be out on the factory floor. On a car assembly line, such system provides a trigger on when to initiate production and helps assure that material is pulled through by demand as opposed to pushed through. In a hospital, there are similar benefits plus some others. For example, if workers on a traditional assembly line run out of parts, they will likely make it their supervisor’s problem. In a hospital, the thought of running out of some necessity makes nurses nervous. They are consequently prone to squirreling away supplies in various locations. Inventory records are consequently haphazard. At Seattle Children’s, formalizing the replenishment system (and making it work) has given the nurses the confidence that what they need will be there. The no longer maintain private stashes and the inventory records are then correct.
Here’s another example related to managing how patients — and their parents — flow through surgery:
Using C.P.I., the hospital has reduced the waiting time for many surgeries from three months to less than one. Recently, the bottleneck was not the surgeons’ time, but a lack of available inpatient beds for recovery. Examining the hospital’s census, administrators saw that there were empty beds on weekends. They realized that by scheduling more surgeries on Fridays, patients could recover over the weekend, when more beds were free. The change also benefited parents and patients who would miss fewer work and school days.
Lack of space in the recovery room was another logjam, and the hospital planned a $500,000 renovation to enlarge it. But a C.P.I. team saw that if a child’s parents went to a common waiting room during surgery, instead of an individual recovery room, more surgeries could be scheduled. Parents were given beepers to alert them when their child would arrive in the recovery room — and maps and colored lines on the walls helped point the way. Plans for the expensive renovation have been scrapped.
Measures such as these have paid off for the hospital. Its cost per patient actually fell 3.7 percent last year. From the article, it seems that much of that saving comes from simply seeing more patients — that is, doing more with the same resources.
It also seems that they have truly adapted lean as a way to continuously improve. As with any lean implementation, it is easy to fixate on tools (Look! We handle our supplies in the ward just like an auto plant!) but the real action is on looking for ways to always make things better even if this is done very incrementally. That means first recognizing that people are actually participating in a process and that work can be standardized. It is then possible to test alternatives to see whether it makes things better. At Children’s this is known as continuous performance improvement or C.P.I.
At Seattle Children’s Hospital, Dr. John Waldhausen, the division chief of pediatric general and thoracic surgery, acknowledges that he and other doctors weren’t initially very enthusiastic about C.P.I. because they thought it would take some decisions about patient care out of their hands.
Over time, he changed his mind, and he is now a vocal advocate of C.P.I. “When you look closely, C.P.I. is the same scientific method we learned in medical school, including hypotheses, data collection and analysis,” he says. “It is not opinion and conjecture — it is data-driven.”
This is obviously something that can work in other hospitals. The hard part is commitment and leadership. Money has to spent on training and everyone from doctors to housekeepers has to believe that the system is for real. That can be hard to do but when it works, it can work really well.