Artículo Lean Healthcare Group

Lean Healthcare Case Studies

Lean Healthcare Case Study

Copyright ©2007 Lean Healthcare Inc. (LHI) All Rights Reserved. www.leanadvisors.com/Lean/Healthcare/

Lean healthcare initiatives don’t have to be overly complex. Sometime you just have to identify the problem, spend a little time identifying the solution and then implement the solution. Other times it’s as simple (or as hard) as finding time to implement a known solution. This is one such case. A behavioral health department had a long lead time from when the patient first made contact until their first appointment.

Behavioral Health

After completing the value stream map, two waiting areas were noted. The first wait took place after the phone interview. The phone interview was a triage activity that fast tracked any patients that were thought to be at risk. The other patients were put on a list and then the list was reviewed at a weekly staff meeting where the patients were assigned to a worker.

The issue was that the triage employees prioritized their work by talking on the phone to patients being the most important and keeping the list up to date was a secondary activity.

By phone, the patients’ information was taken down and when there was time, the list would be updated and entered into the computer. Over time, the patients waiting to get on the list for the staff assignment was growing. When the team took on the assignment to reduce the waiting list it had grown to 85 potential patients.

The team put together a Future State Implementation Plan that would bring the backlog down to zero and then another Plan to keep the wait time, to be assigned, to less than one week. Within six weeks of starting the Implementation, the team was successful in reducing the backlog – see the graph below. There were 10 interventions in order to be successful. Since then they have implemented a process that ensures all the patients that phone in are given a first appointment time within a week of calling.

Many times the employees in the value stream mapping process tell us ‘they already know the problems’ or when a problem is identified ‘they say that they already knew about it’. In this case the employees knew there was an issue however they couldn’t free up anytime to resolve the problem, so they did the best they could. The Enterprise Value Stream Mapping™ process that they went through with Lean Healthcare Inc. helped management ‘see’ the issues and ‘see’ the Future State that could be. This understanding of the Future State, by all staff and management, was the motivation and knowledge they required, for them to become serious about solving the issue of ‘wait times’ and assign time for the employees to resolve the problems.

The results were quick and impressive. In six weeks the backlog (85 patients) was gone. Patients calling in were assigned to a worker and given an appointment within a week; this was down from the 5 weeks that were initially required.

Of course, the other benefits are the patient satisfaction and staff pride in their work. This team has changed their thinking and will always be searching for ways to provide even better service and assistance to their patients using Lean.

This first Future State transformation is not the final solution. The group is now excited by their success and the team is now working on their new goal of assigning an appointment for the patient at the time they call the triage area. The Lean process is one of continuous improvement and an ongoing desire to make all processes better.

For more information, please contact us at 1(613) 821-4545 or visit us on the web: www.lean .com/Lean/Healthcare/advisors

http://www.leanadvisors.com/Lean/Healthcare/



Reducing Waiting and Frustration for both the Patient and Staff

Lean Healthcare Inc. has worked with Emergency Departments (ED) at hospitals. And like all emergency departments, the staff in the Emergency Department work under enormous stress and the workload has continued to increase impacting wait times. This type of environment creates an atmosphere of frustration and anxiety.

In this particular case, the Emergency Department team was introduced to Lean. Not surprisingly, the team thought that they were unique and that there was just too much variation in their work to apply any methods or concepts that would help them.

Lean Healthcare Inc. convinced them to complete a Current Value Stream map. The map included all processing steps from the moment the patient presents themselves to Emergency Department, to when they were either treated and discharged or admitted to the Hospital.

A Future State Map was then created focused on improving flow and handoffs between several critical processing steps. The team was surprised that within their unique environment that there was a number of opportunities within their control creating variation beyond what would be considered or expected by natural variation.

A significant problem within their Value Stream was the variation and lack of standardization in terms of how different team members conducted their assessment, testing, care and treatment. A major kaizen was planned and organized with the goal to develop standard practices to reduce patient time in Emergency Department (reduce the waste of waiting) and providing optimum care (improve quality and service).

Other issues identified, were with the delays experienced by Emergency Department in terms of waiting for the Hospital Admissions physician to show up in Emergency Department before a bed could be requested and the time it took to get a bed assigned.

The impact of this waiting was:

Emergency Department: Registration & Admission

• An increase in unnecessary wait time for the patient in Emergency Department

• Unnecessary stress and patient dissatisfaction

• Unnecessary stress and frustration of the staff

• The rooms in Emergency Department were filled by patients waiting to be moved

• The arriving patients had to wait longer for an Emergency Department room

• The Emergency Department nurse was spending much more time providing ‘hospital floor nursing care’ rather than Emergency Department ‘nursing care’.

The result is the team that thought they were unique, and that the status quo was the way it had to be, are now motivated to implement changes in their information flows and communication flows in order to improve the entire end-to-end system. The team has just started to implement a number of the planned changes to improve flow in the emergency room, and reduce patient wait time, and overall stay from arrival to discharge. Once they complete the Future State in three months, they will have reduced the wait times by 25% to 40%.

The other side benefit, but a very important one is, staff morale and pride in their work will be improved.

And all this will be accomplished with no extra equipment and no additional staff.

For more information, please contact us at 1(613) 821-4545 or visit us on the web: www.leanadvisors.com/Lean/Healthcare/




Emergency Room Call Triage While critically sick or injured patients required attention, the outside world was phoning the ER asking questions such as, who was on call, I have a headache should I come down to the emergency room? While each call was very important to the

caller, the fact is that the emergency rooms are not allowed to give out

certain confidential information or consulting over the phone on what ails you. These calls were particularly bothersome on the off-shifts when

the staff is greatly reduced. The nurse didn’t know how

important the call was and in many cases had to make a decision on whether to stay with

a patient or answer the phone. To exaggerate the problem even more, the calls were also coming to the ER from all areas/departments within the facility. It could be call from a ward wanting to know who the attending physician was or it could be the front desk inquiring about one of the emergency room patients. The emergency room had no way to triage the phone calls to determine what the priority was.

The challenge facing the emergency room was they were being interrupted constantly and always at the wrong time. This created a great deal of stress/pressure on them and the incoming calls amplified the problem. So, ultimately they wanted to be able to answer the calls that they should deal with and not be interrupted by the calls that that should have been directed to others. In addition they wanted to ensure the caller was responded to with little or no delay.

This emergency room discovered this issue during the Enterprise Value Stream Mapping™ (EVSM®) process. EVSM® is a Lean tool that allowed the emergency room team to look at their process from end to end and identify the areas with the most opportunities for patient improvement. The opportunities were prioritized during the development of a detailed Implementation Plan using the Future State Map as a guide.

Using specific problem solving techniques the staff identified the main causes of call interruptions. The team found that more than 50% of the calls should be handled in another area.

An Advisor from Lean Healthcare Inc. helped the emergency room team work through a Kaizen event aimed at reducing the number of wrong calls to the emergency room. They identified a solution that would route the calls and direct them to the proper area.

At the completion of the event the team had met their goal of reducing the calls by over 50%. The success of the event amazed the employees who were accustomed to changes taking weeks or months to complete, and even then not necessarily getting the dramatic results they expected. They were also impressed with the cooperation from the support departments such as the information technologies department that helped them quickly set up the phones to properly direct calls. With the Current State map in hand, the ER team was able to show the IT department, and other support groups, exactly the problem they were having and what they required for their Future State. With this information, the IT team was able to design a solution quickly and make the modifications to the system with very little effort.

As for potential patients that were calling in for advice, the results were seamless. One of the major impacts of this change was the improved service to the client/patient. In the past, they would be told by the emergency department that they could not give out advice on the phone and would be given another number to call. This was a source of much patient frustration as well as frustration for the staff. Now, with the new ‘process’, the patient receives the desired medical advice immediately and the staff are able to remain focused on what they were professionally trained to do – provide medical assistance to those that need it.



Lean Healthcare Case Study Hospital Food Services Hospital food, what comes to mind when you hear those words? For many it’s the thought of cold coffee, poor presentation, bad service, served at times when you don’t want it, or perhaps it was served while you were getting a test.

One hospital is working to change the way we think of hospital food by making it more like room service from a five star hotel. They are introducing ‘meals-on-demand’, giving patients an opportunity to place orders for food around their schedule, rather than the hospital dictating the schedule. Meals-on-demand is becoming more and more popular in

patient service at many hospitals. This is a challenge in an area where batch processing has been the norm in order to keep costs down. The food is prepared in batches, served in batches delivered in batches and cleaned up in batches. The new paradigm is to go to single meal flow. The challenge is how to add the service without adding significantly more cost.

One hospital’s has turned to the strategies of Lean to help them

achieve this goal and Lean Healthcare Inc. was given the

opportunity to work with the food services team in order to achieve this.

The team first started by Enterprise Value Stream Mapping™ (EVSM®) the Current State process from the makeup of the trays to the delivery of the trays to the patients to the retrieval of the used trays. During this process the team observed many of the wastes identified in non Lean operations. Wastes such as waiting, over processing and even over production were observed. Patient surveys and complaints were also assessed and these comments were collected.

During the preparation and serving of the food it was like a race with the preparers pushing the servers and the servers racing in and out of rooms to keep up. Little time was available to greet the patients and answer questions; otherwise the trays of food waiting would get cold.

The next step was to create a Future State that would eliminate the wastes and produce a more Lean process. Based on the Future State, we wanted to achieve, we put together an Implementation Plan that covered the next couple of months.

It was decided the first critical step was to improve the current methods in order to prepare for the more challenging meals on demand.

At the completion of their first Future State there were significant improvements. An old unreliable piece of equipment was eliminated. This saved electrical costs as well as repair and maintenance costs.

Three positions were freed up that will be used to increase the staff that will deliver or prepare the food. The result was, they were able to add valuable resources that will be required to serve the patients when on-demand starts. Pull and flow from the preparation of the trays of food to the delivery in the wards was created in the system so that the food was always fresher and didn’t have a chance to cool down while waiting or sitting in the cart.

Many of the ideas were quite simple; the Lean initiative gave employees a mechanism to voice their ideas. An end-to-end process was put in place that would allow coffee to be served hot on-demand to patients; other suggestions included ideas that eliminate plastic tops and paper products that make the service more environmentally friendly.

This transformation in the thinking and process had a positive outcome which didn’t cost the hospital any additional staff or any additional equipment – in fact, the hospital freed up several staff to do value-added work and removed some old legacy equipment that required constant repair and maintenance. Most importantly, it helped to improve the quality and service to the patient/client and improved the staff morale, which is what Lean is all about.






Core Laboratory Healthcare organizations are faced with a very real dilemma of rising costs and the need to provide healthcare services to an ever demanding, ever growing population. Many initiatives have been undertaken over the last number of years with good intention but relatively limited success. Healthcare organizations are asking how Lean can work for them.

Initial Lean applications at most hospitals have started within a Lab environment. Although Lean has a place in any organization and type of environment, Labs have been seen as a good area to start. Is this because Labs are where the most waste – absolutely not! Healthcare administrators simply see Lab processes as those that most resemble manufacturing type processes.

When Lean Healthcare Inc. met with a recent Core Lab team, we introduced them to the Value Stream perspective. It became clear that they were a Core Lab in name only. Organization and setup was still based on traditional, functional, silo thinking – Chemistry lab, Hematology lab, Coag lab etc. The Value Stream perspective drove a new way of organizing the Lab that truly broke down the silos and integrated the work to better reflect what the customer needed. This created a fully functioning and responsive Core Lab.

Lead time or Turnaround Time (TAT) in a lab is often the most critical measure of success. However, when looking at this performance metric, it is usually in isolation by test type. However, our customer / client, the treating physician often is ordering a series of tests and it is usually the result from the series of tests ordered that directs the treatment plan. Therefore excellent TAT for one test may be offset by poor performance with another. Therefore, Labs must look at the family of tests that they perform and improvement must be made system wide.

Another critical issue is the variation or the inconsistency in reporting. This performance variation lowered the confidence level of the provider many compensated by ordering Stat tests when they should really be routines. This simply exaggerated and amplified the problems.

Once we have established the family of tests, we work with our lab teams to develop an end-to-end Current State Enterprise Value Stream Map™.

We then apply the fundamental principles of Lean to create a vision, a Future State Value Stream Map.

We then help the team to implement a Plan and improve the flow of work in order to close the gap from our Current to our Future state.

Results for the Core Labs that Lean Healthcare Inc. has worked with have consistently provided similar improvements. Specifically, we see an improvement in TAT time and a convergence of the results of one test compared to another. Our work with teams moves them from a stress filled environment where everyone is rushing around and firefighting to an established and consistent pace of work. By focusing on improved flow, labs have discovered that they have eliminated waste in their processes with a significant positive impact on cost. Reported numbers show a 25-30% reduction in labor cost per test.

Lean allowed the Core Lab to improve seemingly competing Key Performance Indicators:

• Service - Improved Turnaround Time

• Quality - Eliminate of test outliers

• Cost - Reduced labor cost per test

• Culture - Sense of Pride and Less Stress





Haematology Laboratory Objectives

• To streamline work processes • Eliminate waste • To gain improved productivity, lower cost,

and maintain or improve on the existing high quality

• Reduce CBC TAT to 30min or less • Reduce Differential TAT to 60 min or less • Reduce STAT requests • Increase overall customer satisfaction • Free up staff for other activities

LEAN Journey During a six-day workshop, a Haematology focus group was introduced to Lean Principles and underwent intense sessions focused on analyzing and mapping the current processes. The first three days of the workshop consisted of practical exercises combined with discussions to clearly reinforce the LEAN concepts. The last three days were dedicated to Enterprise Value Stream Mapping™, which included the development of the Current and Future State Maps of the Haematology Laboratory (“Laboratory”).

The workshop was rounded off by the development of the LEAN Plan (Implementation Plan), followed by a communication campaign. Information and poster sessions were held, which provided opportunity for information-sharing and receiving feedback from staff. The focus group participants were on hand to present their “Lean findings/observations” and looked for input from the rest of the staff.

Our Experience Current State Mapping The group’s initial steps in the Value Stream Mapping exercise were to create a Current State Map. As mentioned, Enterprise Value Stream Mapping follows a product or service from beginning to end (including Information flows), and constructs a visual representation of every step in the process. Accordingly, the Laboratory built a Value Stream Map that included all the value-added and non-value-added steps in which Process Flow, Information Flow, and Timelines were incorporated. This tool took the complexity of the laboratory’s staff work, and provided them with a simple and complete illustration of their process, including the value added and non-value added activities.

Future State Mapping According to the first LEAN Principle, focus on creating value from the perspective of the client. With the Current State in front of them, the group began to construct the Future State Map. They began by identifying Product Families (grouping tests by common activities and utilize the same resources), and focused on the ones with the highest test volumes (CBC and DIFF). Focusing on the product families with the highest volumes allowed them to remove peripheral activities from the main flow and to introduce continuous balanced flow to the process. For example, the group focused on the CBC (high volume) and kept it simple: Receive, move it to stage of analysis, analyze, determine if slide is required then make smear or store. The lower volume activities such as sorting the CBC’s for Sickle, G6PD, ESR were worked out of the main process.

Subsequently, the group proceeded to determine the Takt time. Takt time can be defined as the rate of customer demand and can be calculated by dividing production time by the quantity the customer demands at that time (volume). Knowing the Takt time helped to determine the resources required (capital and human) to meet the demand (the heartbeat of their system). Based on the Current State, the focus group identified areas where they could introduce continuous flow. Controls such as smaller batches to be delivered by accessioning (3-5) and no more than 3 racks waiting to be analyzed would be the cue to shift resources to meet demand. See Figure 3 for the Future State Map.

Developing and Implementing Changes The “Implementation Plan” guided the change process, which consisted of eight identified Kaizens and associated timelines. (Kaizens are issues identified for improvements that are dealt with in continuous and incremental steps.) The general premise for how to achieve the Future State was to break the Future State into small manageable pieces (Kaizens). For each Kaizen, a Lead was assigned to work with a group consisting of front-line staffs that were intimately familiar with the area of focus to develop and implement practical solutions.



Some of the initiatives that occurred surrounding the Kaizens in order to achieve the Future State were:

Standardization of equipment This was achieved by replacing existing non-identical analysers with new identical ones. The benefits of this allowed us to have one set of procedures and review criteria. It also allowed us to distribute the workload equally between analysers.

Remove bottleneck between accession-ing and analyzing The practice of sending specimens to a set-up area to be smeared and checked created inventory and increased the time between accessioning and analysing. This non-value added step was eliminated and specimens allowed to flow directly from accessioning to the analyzer.

Revised criteria for smear review With the introduction of new analyzers, the focus group took the opportunity to revise their smear review criteria to take advantage of newer technology. This important step allowed them to change their practice from making smears on all slides (which required staining and sorting whether they needed them or not) to making smears only when required for review. The end results were less time wasted on making, staining and sorting smears, and cost saving due to less required reagents.

Elimination of paper requisition

The practice of having the requisition follow the specimen and having to reconcile it with instrument printout and slides was determined to be a non-value added activity, therefore was eliminated. This was replaced with using the instrument printout with patient demographics to be reconciled with slides for review.

Increase the number of 2 ml collection tubes used for collection Collaboration with the Phlebotomy Dept. was undertaken to increase the number of 2 ml collection tubes in order to enable the Laboratory to reduce the amount of specimen handling required, and to take advantage of instrument features to increase efficiency.

Smaller batches and introduction of FIFO (First In-First Out lanes) Batches of specimens delivered were reduced from accessioning to the analyzer by increasing the frequency of delivery. The smaller batches allowed the staff to analyze specimens on a FIFO basis. The racks provided a visual cue to let the staff know when more or less resources were needed to maintain continuous flow.

Consequently, there have been several improvements seen so far in the Haematology Laboratory as a result of LEAN.

LEAN Improvements Turnaround Times All routine CBC TATs reduced to less than 20 mins from 30 to 40 minutes previously.

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Fig.5: Following implementation on March 22/06, initial increase in TAT was experienced due to process change (learning curve), but subsequent reduction in TAT of 50% followed.



All differential times reduced to less than 40 mins from approx. 80 minutes.

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Fig.6: Following implementation on March 22/06, an initial adjustment period (learning curve) was experienced, but TAT for Smear review/Differentials were subsequently reduced by 50%.

Number of smear reviews reduced to less than 40% from 80%.

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Streamlined Process See “Developing and Implementing Changes” above. Fewer Staff Required The LEAN changes enabled the Laboratory to process the same volumes of work with fewer staff members. This has created the opportunity to cross-training staff in more labour intensive specialized areas (e.g. Flow Cytometry, Hemoglobinopathies).

Fewer Calls to Call Centre Improved TAT has reduced the number of calls by 25% to the Call Centre with inquiries about results, allowing the call centre representatives to better manage the incoming calls and provide a more attentive service. Reduction in Safety Report Improved TAT has greatly reduced the number of Safety Reports (complaints and incident reports).

Customer and Employee Satisfaction Improved service to the Laboratory’s end users created increased customer satisfaction as indicated by the reduction in complaints. Streamlining and “flowing” the work to make it more manageable

reduced stresses on staff and increased work satisfaction. Staff comments like “It doesn’t feel like I am doing the same amount of work as before.” and “I don’t feel worn by the end of the day like I use to.” are indicators of employee satisfaction.



Conclusions Laboratories are under continual pressure to maintain service in the face of increase demands and shrinking resources. The Lean exercise provided the Haematology Laboratory with tools necessary to systematically eliminate waste and speed up the process, regardless of the form that it exists within their process, thus enabling the Laboratory to survive in an environment by “doing more with less”. The results obtained such as reduced TAT and streamlined processes have permitted the Laboratory to further efficiently meet the demands and expectations of its customers.

Factors critical to the success of LEAN were strong leadership (the support from senior management and the commitment of the value stream leaders), communication and input from frontline staff, as well as constant and timely monitoring by managers to effectively address issues as they arose.

Future Developments The Haematology Laboratory will continue to build a LEAN Culture by continuously applying the LEAN Principles in order to gain further efficiencies and to improve process. Having experienced success, the Laboratory plans on applying the lessons they have learned to other areas of the DPLM, such as Coagulation, Biochemistry, TDM/Toxicology, Microbiology, Pathology, and Phlebotomy; as well as it endeavours to share their knowledge and experience with other laboratory and health providers. For more information, please contact us at 1(613) 821-4545 or visit us on the web: www.leanadvisors.com/Lean/Healthcare/




Laboratory Specimen Receiving When improving an end to end process it is usually better to start at the end of the process closest to the customer. In a

Laboratory environment, the delay may be waiting for the specimens to show up at the workbench. This is an example of one such case.

When the Current State Map was completed, it was noted that the work was processed in large batches. The courier delivers one or two large batches of samples to receiving every day. The large batch is emptied from the boxes, and then sent over to be accessioned as a batch and finally distributed at the end of the day to the various workbenches in another batch.

Employees get lulled into a batch mentality and actually think it is the best way to process their work – this type of thinking is what you find in every industry including manufacturing, administration and service. We find in Laboratories that one piece flow isn’t even considered in such a set up and most employees question the sanity of anyone that would propose a one piece or smaller batch process.

One receiving lab did take on the challenge to reduce batch sizes and work toward one piece flow. Circular logic was used as the reason for one large batch. This logic is true in many companies in many operations. In most of the labs we work in, you ask ‘why all the work is distributed at the end of the day’. The response from receiving is something to the effect - “that’s when the departments want to start the tests”. When you ask the technicians why they start their testing at the end of the day, they tell you “that’s when they get the specimens”.

What you discover when applying the Enterprise Value Stream Mapping™ tool is, the delay due to batching the specimens adds an average of 4 hours to the turn around time (TAT) of all the tests and for some it could be up to 24 hours. It also sends a message that there isn’t any urgency to delivering the specimens.

The only visual measurement goal in the receiving area was meeting the 4 pm deadline for delivery. As this was the only measure, employee output was variable. Some days there was a lot of work and other days there was less. This is not a good work environment, where you are overworked one day and under worked another. In fact, it causes the staff a great deal of pressure and undue stress,

Lean Healthcare Inc. worked with the supervisor and his team on improving the delivery and measurement in his area. One of the benefits of Lean Labs is the interaction between all the departments.

As part of their Future State Implementation Plan, the team met with their internal customers and determined when the samples would be required to meet the patient demand (Takt time). From this analysis, they set up a schedule and started to deliver smaller batches.

Pitch is a measure of the pace of work flow with regard to the patient demand. The supervisor developed a visual method for measuring the team’s performance against patient demand. This ongoing measure was designed by the team, so that it was visible and understood by everyone in and out of the area. From this measurement, they (the entire lab personnel) can tell if they are ahead or behind at any time throughout the day.

The results have been impressive. Within the first week of smaller batches, the end-to-end process for some of the tests had improved by 25%. With the implementation of the smaller batches the throughput of the department improved as well as the capacity. The lab is receiving 75% more product, with 33% fewer staff and delivering the last specimens an hour earlier.

With the reduction in staff required to receive the specimens the supervisor was able to re-assign the employees to work on another value stream in the area that was unable to keep up.

And another result that is more difficult to measure, but is just as important as all the others, is staff morale and attitude. The transformation has staff excited about the changes and has created an environment where they have much more pride in the work they are involved in and the exceptional service they are providing to their doctors and patients.




Copyright © 2007 Lean Healthcare Inc. (LHI) All Rights Reserved. www.leanadvisors.com/Lean/Healthcare/

Hospital Maintenance As with most support groups in an organization, the feeling you get, at times, is that you are a disciple and not necessarily recognized at the same

level of importance as other groups. With this positioning, it can be difficult to be recognized as a

leader to other groups and as an example for them to follow.

One maintenance department in a hospital was able to achieve this goal of being a leader when they successfully applied 5S.

The maintenance group was located in the basement of the hospital and by default they became the dumping ground for used or old equipment, damaged equipment and equipment that didn’t have a home. As well, their location was the basement - it was out of site and it was considered less clean and maybe it didn’t need to be as clean. And this type of thinking by the staff seemed to lead to the acceptance that it was ok to pile ‘stuff’ into any area that was open. Adding to this situation, was the fact that supervisors and employees in maintenance came and went, through natural attrition and organizational changes, which meant that material accumulated and nobody knew where to find things. It soon became a frustrating and an unpleasant task, just to find items when they were needed. When, and if, the items were eventually found, it usually meant moving material around to get to the item they wanted. It was not unusual to spend a half day or more searching and moving.

Pre 5S - Lockup Area

In this area, there was also equipment that was designated good but no longer required and was to be donated. The problem encountered, in this situation, was that the donation equipment was sent by the truckload. But because the items were so scattered, no one really knew when there was a truckload ready. The area the employees worked in became an area for storage of material and work in process. Tools were hung up using shadow boards and looked very organized. However, many employees had difficulty reaching over workbenches to get them. They felt they were running out of space and they were feeling no one noticed or that it just didn’t matter.

Pre 5S - Shop Area

The challenge facing the maintenance team was to clean up the areas, make them visual, and put a system in place to prevent the area from becoming cluttered again and to convince everyone to sustain the results.

With the help of Lean Healthcare Inc., the maintenance team was introduced to 5S. The 5S’s are:

1. Sort 2. Set in order 3. Sweep 4. Standardize 5. Sustain

One of the most difficult undertakings in a 5S event is to identify an area that the “red tagged” items will go. These red tag items are items not required to get the work completed by that particular area of the department.



The team’s first priority was to clear out a room that was approximately 20’x40’ with about 60ft² of open floor available. The remaining area was cluttered and to get from one end to another you had to climb over material.

Pre 5S - Lockup Area

Important to note - prior to starting the 5S initiative, maintenance was one of the areas with the highest injury-on-duty. The clutter, they contended with, was certainly a contributing factor. For this reason, they decided it would be the first area to be 5S’d.

The results have been astounding. In an afternoon, they completed their sorting and freed up over 600ft² or about 75% of the room. The next day the concrete floors were painted. Racking was set up and labeling completed. Any new items going into the area require a red tag that includes when the item will have a disposition.

Post 5S - Lockup Area

They didn’t stop there. They continued through the entire basement level, cleaning and sorting. With the new freed up space, they were able to keep equipment, being repaired but waiting for a part, out

of the main work area. They moved workbenches away from the wall so they could work around items on the bench rather than twisting the item and themselves around. They even had the option (which they didn’t before) of having two employees work on the same item at the same time. Now that the benches were away from the walls, stretching and reaching was eliminated. And the employees could now walk right up to where the tools were stored to retrieve them properly and safely.

Another benefit from the 5S exercise was they freed up enough space to layout an area the size of a semi trailer where they place the material to be donated. When the area is full they know (it is visible to all staff) that they should order a truck and have it taken away.

The group also discovered many tools and parts that they never knew they had. In fact, they found there were things they kept ordering and the reality was they already had the parts and material in stock.

This 5S event has made the maintenance group a leader in their organization and they have gained and earned much respect along with self pride in their jobs - departments are asking them for their help to implement 5S in other areas. They also have gone over 120 days without an injury!

Congratulations to this group! They are now able to independently apply 5S without the need for outside consultants. That is what we at Lean Healthcare Inc. call a ‘Success’.





When Lean Healthcare Inc. met with a recent Hospital team we

introduced them to the Value Stream

perspective. The Enterprise Value Stream

perspective identified that there were a

number of different functions that contributed to the ultimate outcome; getting the result to the customer.

Hospital Phlebotomy

In particular, the Enterprise Value Stream Map™ captured the work of the Phlebotomist from collection at bedside or in the clinic, to Lab Receiving, Test Prep, and Testing to Resulting. Clearly, all of the staff in these areas, throughout the hospital, was working hard, yet the results did not reflect this effort. As in most organizations, this inconsistency in meeting the needed requirements of the various clients, often lead to finger pointing rather than a collective effort to problem solve and improve the end-to-end process.

Lean Healthcare Inc. worked with this team to create a visual representation, our Current State Map of the end to end flow of work from the patient to the final result back to the physician. We then applied the fundamental principles of Lean, Flow and Pull to create a vision. This became our Future State Value Stream Map. This helped to identify what we needed to do to close the gap between the Current State and the Future State. This list of things to do became our Implementation Plan. It identified all of our Kaizens and the sequence in which those kaizens should be completed. A Kaizen is a focused burst of energy and effort by an implementation team to achieve a specific result. We then assisted the team to implement the Plan and improve the flow of work in order to close the gap from our Current to our Future state.

A specific Kaizen involved a large team of Phlebotomists at the hospital responsible for collection at bedside and the hospital outpatient clinic. The Kaizen team examined how the collections were currently being done. They brainstormed and came up with ideas based on Lean Principles that improved their completion times for am (morning) collections.

The team identified a number of examples of Motion and Travel Waste that contributed to the delays in completing their draws. As a result of their efforts, a new collection system was introduced. Results of the changes were immediately noticed by the staff in all departments. The chart below identifies a 38% improvement in collections within the first two weeks while volumes actually increased.

This allowed for better turnaround time more predictability in the end-to-end process from collection at bedside or in the clinic, to Lab Receiving, Test Prep, and Testing to Resulting.

This kaizen in conjunction with others within the end-to-end Value Stream contributed to an overall improvement in Turnaround time (TAT) from Collect through to Result. The team was now focused on looking horizontally along the Value Stream. The entire group was working together as one unit. They were focused on how each process could support one another rather than simply focusing on optimizing their own function.





Hospital Surgery Prep Center Day surgery is a busy healthcare work environment at most hospitals. Like many other environments we are working with, the Surgery Prep Center at a hospital was faced with enormous challenges that include significant growth in demand creating lack of space and rooms, in addition to resource variation from procedure to procedure and from surgeon to surgeon. This team, like many other’s, saw the benefits of Lean but could not imagine how they could apply it within their own ‘unique’ environment. The greatest challenge for us was to focus not on why we can’t do anything but rather on how we can do it. Once we overcame this hurdle, our team was ready to creatively challenge the status quo and attack waste.

The team was a cross-functional team of healthcare workers and clerical support staff gathered to address the many issues that they faced day to day. As is the case in healthcare, it appeared that no two days were ever the same. There was always a new mix of procedures happening, with a varied mix of surgeons and patient populations.

Combined with these ever present issues is the need to help and manage anxious family members.

This scenario became our reality, our starting point for introducing Lean in an active Surgical Prep Center. The team created a Current State Map from the initial appointment for surgery to the actual patient arrival, registration, pre-op through to the actual procedure and recovery. The Current State Map was our attempt to try and understand the chaos that the staff works through every day to support the patients and surgeons. The Current State ‘Enterprise Value Stream Map’™ followed two processing streams, the patient flow and the patient information/ chart flow.

It soon became evident that there were a number of processes that weren’t working as effectively as possible. These included:

Chart preparation done days in advance of actual surgery that resulted in a number of different people having to touch and update the chart.

No one person was responsible for putting together patients chart. There were at least 3-4 people involved in putting some aspect of information together. Finally, the chart had to be checked by a nurse to ensure everything was present.

Patient information was being copied and then constantly updated and corrected at both the Surgery Prep Center and at the scheduling Clinic, because of the early Chart Preparation.

Patients showing up or being scheduled to arrive earlier than necessary.

Doing Pre Op too early with patients resulting in staff being tied up working with the wrong patient, and tying up the Pre Op rooms.

Staff balance was difficult to manage between the different areas of the Surgery Center. At times some staff would be scrambling trying to keep up with the demand of the surgeons while other staff had a less demanding workload. Nurse Manager and the nurse leads spent much of their time trying to re-balance patient load to staff.

Time for same procedures varied from patient to patient.



Time for one procedure is different than time for another procedure.

Nurses were responsible for contacting patients prior to surgery.

There appeared to be a wide range of valuable nursing time spent with the patients on the phone that seemed dependent more on who was calling rather than on the patient or nature of the procedure.

The development of a Future State ‘Enterprise Value Stream Map’™ focused on improving Flow and or creating Pull from the Surgeons. The team developed an implementation plan. Significant changes were introduced with both the patient process and the patient chart process. The goal was to create a Surgery Prep Center focused on improved patient care and satisfaction with less waste and an improved work environment.

The following initiatives were introduced:

Just in time Chart preparation.

Understanding the Pull from Surgery and setting Prep up to work to this pace.

Breaking Prep into work groups that align with the Surgery schedule.

Determining number of rooms required for each work group.

Assigning staff to support each work group

Develop standard message for pre surgery patient contact.

Introduce a call type system that brings family into the unit just in time to support patient in recovery and participate in post surgery education.

The team had a number of difficult hurdles to overcome in their effort to introduce improved flow through this area. The team learned to involve and communicate to as many stakeholders as possible throughout implementation. The changes introduced positioned the area to meet the greater demands placed on the unit while keeping patient care and patient satisfaction front and center.

Congratulations to this team of passion and courageous team, for their efforts and application of Lean in this difficult hospital environment. Keep it going!



Artículo Lean Healthcare Group

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