The Lean Hospital

The Hospitalist. 2008 June;2008(06):

June 1, 2008|The Hospitalist

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

A Lean Discharge Case Study

Waiting to be discharged from the hospital is frustrating for patients and costly for hospitals.

At the University of Michigan Medical Center in Ann Arbor, the discharge process was taking too long, according to Christopher Kim, MD, a hospitalist there.

Discharge was a three-step process. First, physicians had to write discharge orders. Next, clerks had to prepare them. Finally, nurses had to give patients their discharge instructions. It was a formula for lots of waiting time—“waste” in lean terminology.

The lean team “found that everything was happening in a serial basis,” Dr. Kim recalls. “Clerks would only write orders when the physicians finished and the nurses would not do anything until clerks finished.”

Physicians often would tell their patients they were to be discharged but fail to inform the nurses. “Nurses would find out from the patients,” Dr. Kim says. It was sometimes hours before the physicians got around to writing up the orders. No orders meant no paperwork. No paperwork meant no nurse-patient instructions. One bottleneck would delay the entire process.

The lean team instituted a parallel procedure. Now, Dr. Kim says, “Discharge order slips are available at the patient’s bedside.” Those forms go directly to the clerks, who notify the nurses, who then begin their discharge instructions. In theory, no one is waiting for anyone else to finish one job before starting another.

In practice, discharge time has decreased from about 195 minutes to 89, a 54% reduction. Knowing early how many beds will become available each day has “also eased the backlog of patients in the ER trying to get into beds and offloads workloads at those places,” Dr. Kim says.

There still is room for improvement. “It’s still a work in progress,” Dr. Kim admits. “We’re still working on our doctors to write their orders even sooner. That’s our next goal.”—CB