We believe that Lean principles can dramatically improve both the efficiency and quality of health care, while simultaneously lowering costs and improving staff morale. Although we think Lean is a useful tool for addressing overcrowding in the emergency department (ED), it often meets with resistance among health care administrators who don't believe manufacturing principles can offer anything to the health care services industry.

While it is, in fact, more difficult to implement Lean in the health care service industry, we believe that the health care system has a greater need for the approach because delivering health care is actually much more complex than most manufacturing businesses.

According to Lean methodology, the more complex a process, the more opportunity there is for problems. And we all agree that health care processes are complex. Unlike most manufacturing assembly lines, in health care, no two patients fit the same mold. Variations in patient diagnosis, medical histories, family background, spiritual beliefs, and emotional issues make every patient unique - yet each expects the same quality and efficiency in care delivery.

Seeing Patients as Customers

Most of us believe it is a generally accepted fact that our hospitals are more crowded than ever, and our EDs are bursting at the seams treating patients. We want solutions to help us treat patients quickly and efficiently, without sacrificing quality. But we balk at thinking of our patients as "customers" and looking at them through the prism of Lean principles.

But we must remember that every patient is also a customer of a service or service type when they enter our hospitals, and treat them as such. Starbuck's would hardly make a customer wait 48 hours for a cup of coffee. However, each day our patients wait hours, even days, for hospital beds, not getting the level of care they need in a hallway or other holding area. Lean brings health care a lesson from companies like Starbuck's - a good product delivered quickly and efficiently and at a price the customer' is willing to pay.

Lean is always viewed through the eyes of the customer. Any work, time or supplies that were used to provide a service is considered waste if it adds no value in the eyes of the customer. Anything that can be looked at as a service process can benefit from Lean. Patient throughput is a service process, and although Lean is very new to health care, there is significant potential for it to trim the immense amount of waste that exists in hospital patient flow - or non-flow, as is the case so often now.

Understanding Lean Principles

Through Lean principles, decision-making is always supported by data - a trait shared with medical care delivery. Lean data are gleaned from tools such as 'Flow Charting' and "Time-Value Stream Mapping.' Flow Charting identifies the process, or list of activity steps, for a particular health service. It forces us to ask whether the customer will pay for this step, and if not, why are we doing it?

See the Flow Map of the Triage Process at York Hospital.

Ideally, every step in a process will add value for a customer. Once these activity steps are identified, the next task is to undertake Time Mapping, which analyzes the time spent on each particular activity in the workflow.

For instance, In hospital ED triage, Flow Charting and Time-Value Stream Mapping will identify the triaging process that every patient flows through - identifying those activities that are value-added (like direct caregiver time) and those that are not value-added (like the patient waiting for something to be done to him/her) and quantifies the time it takes for patients to experience each. When applied to hospital services like triage, Lean can help us see what is worth doing versus what is a waste of time in patient care.

See the Time-Value Map of Triage at York HospitalNew Link

Applying the Principles of Lean with 'Six Sigma' in the ED

Some hospitals are beginning to couple Lean with a process called "Six Sigma." Six Sigma is a data-driven, highly statistical way of looking at an issue and eliminating defects by reducing variation. Essentially, Six Sigma methodology takes an issue and makes it a statistical problem that can be solved with a statistical solution. Only recently have health care organizations begun applying Six Sigma methodology to their operations, but like Lean, it has been used in manufacturing for decades.

Since it relies heavily on data, advanced statistical analysis tools and real cultural change, Six Sigma projects require a high level of management support when used in a healthcare setting, and are usually reserved for those processes that have the greatest impact on costs. For example, Lean may be better utilized in improving the frequency at which physicians prescribe aspirin for heart patients. Six Sigma might be better applied to analyzing whether there is a link between patient satisfaction, the amount of time nurses work overtime, and the frequency of nursing errors.

Bon Secours Health System in Marriottsville, Md., has completed more than 400 projects involving Lean and Six Sigma in the past five years. One project looked at patient length of stay. Because Medicare uses fixed treatment rates, a hospital gets reimbursed the same amount of money for a three-day stay as for an eight-day stay for treating the same diagnosis. Therefore, it is in the best interest of patients and the hospital to decrease length of stay. When Lean and Six Sigma tools were used to examine this process, discharge procedures were identified as a source of delay. Therefore, to reduce this delay and increase efficiency and velocity (entity speed through the service process), treatment can begin with discharge in mind. By anticipating a patient's discharge needs at the beginning of his or her stay, delays in such things as setting up home care at discharge can be prevented.

Getting Started

After recognizing the need for improving patient flow, the first step for a hospital seeking to adapt the Lean method is to identify the service process of interest and then the activities a patient goes through in receiving treatment. If the service process under scrutiny is an ED process, everyone involved in moving a patient through the ED needs to be involved - triage nurses, physicians, radiology staff, laboratory technicians, admissions, etc. Senior management must also champion Lean hospital-wide to all staff, making it a common thread in solving throughput issues.

It's important to note that while Lean can make a big impact toward improving service delivery, Lean alone will not help a hospital overcome under-capacity. A hospital can have the best processes in place, but if staff is overwhelmed by patient demands that are too high, Lean isn't going to solve the problem.

Lean must therefore be paired with other techniques such as 'forecasting' and 'process simulation' (simulation modeling) - commonly used in other industries - to analyze demand and capacity to serve. Not a lot of hospitals are currently using simulation modeling, but as Lean is more widely implemented in the health care service industry, tools like these will have to be introduced to better align resources with demand.

Companies like Toyota, Starbucks, Dell Computers, and General Electric have all built successful businesses using Lean, Six Sigma and process simulation tools and concepts. There is critical mass of success stories among manufacturing industries that is only beginning to surface in health care, thanks to places like York Hospital and Bon Secours Health System. As more Lean health care success stories emerge, every hospital administrator and patient care provider will see the importance of Lean principles to patient flow and throughput.

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Doug Sears, M.B.A.
Director of Performance Improvement/Knowledge Transfer
Bon Secours Health System
Marriottsville, MD

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David Eitel, M.D. M.B.A.
Director of Health Services Design, Department of Emergency Medicine
York Hospital
York, PA