Precious effi ciency potential can be

tapped through process management.

Anyone intending to increase the

effi ciency and added value of processes

in a traditional institution like Charité

must be able to proove that this

approach can actually work. A pilot project

in the cardiac catheter laboratory of the

Cardiology Department at Charité

Campus Virchow Klinikum (CVK) has now

provided this evidence. The model project

was initiated jointly with Stryker Lean

Academy in the spring of 2010.

The project’s successes at a

glance:

Two days of ViMotion video analysis of

a typical 45-minute work process

• conveyed lean management skills to

participants

• enabled participants to analyze

processes

• generated enthusiasm and reinforced

team spirit

• revealed more than 30 improvements

in ergonomics and more than 50

ergonomic details that needed to be

improved in terms of occupational

safety

• revealed the potential to generate

additional revenue in the amount of

EUR 300,000 per year from just one

procedure

Not until the end of May 2010 did the

Berlin Senate decide to keep all three of

the Charité’s locations for inpatients.

Despite this favorable vote, it is too early

for staff at this venerable institution to

breathe a sigh of relief. Because of the

precarious budgetary situation, the city

can only provide just under 50 percent

of the funds needed for investment over

the next few years.

Potential for greater effi ciency at

the interfaces with healthcare

So the strict savings program at the

Charité continues – even though the

annual defi cit, despite additional costs

arising from collective bargaining

agreements and normal increases in

costs, such as for energy, have already

been cut back from EUR 56.6 million

(2008) to EUR 19.3 million (2009).

The ambitious target of presenting a

balanced budget for 2011 cannot easily

be reached using conventional business

methods for reducing expenditure. Any

leeway for negotiating price reductions

in procurement is dwindling. Further

cutbacks in personnel, especially in

the clinics, could have a negative effect

on the quality of care.

But there is still potential for healthcare

savings at the interfaces where health

care is provided, such as: when

admitting patients, transferring them

from one specialist department to

another, and moving them between

Detecting errors, identifying causes, improving processes – initial project serves as opportunity to introduce Lean management at Berlin’s Charité Hospital

Founded in 1710 as a less than prestigious plague treatment institution outside

the gates of the city, 300 years later, , Berlin’s Charité has become Europe’s

largest university hospital. Its four locations represent cutting-edge medical

care with a worldwide reputation. Since 2009, the Charité has had even greater

trademark protection to prevent freeloaders from misusing its good name.

Last year, tremendous efforts resulted in a successful turnaround. Charité’s

management expects a balanced budget for the fi rst time in 2011. But

conventional ways of saving money, such as in material procurement or task

loading, have been exhausted in many areas.

Key facts & fi gures on Charité – Universitätsmedizin Berlin¹

• 4 locations (Benjamin Franklin

Campus, Berlin-Buch Campus,

Charité Campus Mitte, Virchow

Clinic Campus (CVK))

• 107 hospitals and institutes orga-

nized into 17 Charité Centers

• 14,500 employees (including

3,750 scientists and physicians,

250 university professors,

4,200 nurses and care assistants, and

746 administrative employees)

• EUR 1.1 billion in annual sales

• 3,200 inpatient beds

• 130,500 inpatient cases handled

each year

• 530,200 outpatient cases handled

each year

• EUR 203 million in state subsidies

• EUR 130 million in funds raised from

third parties

¹ Annual Report 2008

wards, operating rooms, and other

specialized treatment rooms. Although

the clinics make successful use of

clinical treatment paths, these paths

mostly refl ect the processes within the

respective specialized departments

and take too little account of the points

of contact with other departments.

Over the decades, processes at these

interfaces in particular have evolved and

multiplied, and are thus only effi cient

to a limited extent.

Lean management focuses

primarily on customer benefi ts

The Charité worked on introducing tools

for more effi cient process management,

particularly those with lean-management

features that became known in hospital

circles as the “Lean for Hospitals”

concept. Lean management is mainly

distinguished from other quality-

management approaches, such as the

industry-non-specifi c Six Sigma or the

hospital-specifi c KTQ (German acronym

for Cooperation for Transparency and

Quality) programs, by being primarily

oriented towards patients’ needs and its

implementation with and at the

employee base. The model gives

employees a lot of freedom in the way

they implement a project within the

strategic guidelines.

History and philosophy of lean management

Lean management refers to all of the principles and methods for an effi cient

structuring of the value chain in corporate processes. From the middle of the 20th

century onward, the car manufacturer Toyota led the fi eld in industrial production²;

the service industries followed in the nineties, and it was not until recently that

lean management also made its appearance in healthcare (“Lean für das

Krankenhaus/Gesundheitswesen” (Lean for Hospitals/Healthcare))³.

The core ideas of lean management are:

• Defi ning the value of a product or service from the customer’s perspective,

• Identifying the value chain and orienting business processes accordingly,

• Avoiding waste by concentrating on value-adding activities,

• Constantly improving quality,

• Continuous and smooth fl ow of all processes (the “fl ow principle”),

• Directing working procedures towards customers’ needs (the “pull principle”),

• Personal responsibility, empowerment and teamwork,

• Decentralized, customer-oriented structures,

• Open information and feedback processes.

Arguments in favor of “Lean for Hospitals” in hospitals and medical

healthcare centers:

• Treatment must be provided to patients directly and on a highly individualized basis.

• Medical treatment requires several – generally at least three – occupational groups

to be synchronized.

• Reducing variations in service improves its quality.

• Reducing waste (e.g. duplicate examinations, waiting times, unnecessary travel,

ineffi cient storage, etc.) streamlines processes.

Authors

² Jeffrey K. Liker: The Toyota Way. 14 management principles from the world’s greatest manufacturer. New York: McGraw Hill, 2004³ Schön-Kliniken Deutschland; Virginia Mason Hospital, Seattle, Washington, USA

“The success of our pilot project makes me hopeful that we can apply the ‘Lean Hospital’

philosophy to Charité’s other hospitals and specialized departments.”

Dr. med. Wolfram von Pannwitz

Head of Corporate Development at Charité – Universitätsmedizin Berlin

In order to introduce the lean

management philosophy in the company

and after identifying the pilot project in

the cardiac catheter laboratory, the

Charité looked for a partner with proven

experience in the hospital fi eld to

conduct an initial training session and

then provide support throughout the

project. Although many consulting

companies offer lean management

consulting, the Charité’s particular

requirements substantially reduced the

number of potential partners.

A taylor-made concept provided by

Stryker Lean Academy

Stryker does not base its pricing policy

on the individual price of the product but

rather on the total costs of acquisition,

usage, repair and maintenance (total

cost of ownership or TCO). Stryker Lean

Academy has also adopted this

approach; based on its expertise in the

hospital fi eld and its tailor-made

concept, it was selected to conduct the

pilot project at the Charité. The project

was split into a two-day training seminar

and the defi ned task in the Cardiology

Department on the CVK campus,

including a (ViMotion) video analysis in

the cardiac catheter laboratory.

Key facts and fi gures of the

Charité’s cardiac catheter

laboratory on its CVK campus

• Three state-of-the-art X-ray systems

for diagnostics and treatment

• 2,500 patients annually

• More than 3,000 procedures

• Range of treatments: cardiovascular

diagnostics (left and right cardiac

catheter examinations), invasive

treatment of all types of cardiac

Twenty Charité employees took part in

the training seminar held in April 2010: in

addition to nursing and medical staff

from the cardiac catheter laboratory, it

was attended by representatives from

Corporate Development, IT and the

Works Council. The Stryker Lean

Academy coaches began by teaching

the basic principles of lean management

and how these can be applied in

healthcare: What are value-adding

activities in a hospital? How can waste

and bottlenecks in procedures be

identifi ed and avoided through

improvements in process management?

Changing roles to get an unbiased

view of all processes

In order to make it possible for everyone,

including administrative employees, to

experience the processes of a cardiac

catheter laboratory, a 150-m² treatment

area was reenacted in which the seminar

participants simulated a complete

treatment procedure. A core element of

the simulation was the opportunity to

exchange roles among various jobs,

which enabled participants to gain a

new and unprejudiced view of the

working procedures in the cardiac

catheter laboratory. While other

management consultants rely too

much on abstract tasks in their Lean

Management role plays (“Let’s build a

lean car manufacturing facility in

Shanghai”), the Stryker Lean Academy’s

approach was based exclusively on

what happens in hospitals and their role

plays simulate actual on-site processes.

In the evaluation of the simulation that

was carried out concurrently,

participants, documented in detail which

procedures could be used in their

day-to-day work, which processes did

not run smoothly, and which activities

did not add value for the patient. The

core purpose of this evaluation was to

derive real suggestions from the

simulation to improve day-to-day work

in the cardiac catheter laboratory.

These were uncharted waters for most

participants as it was the fi rst time for

many of them that representatives of

various professions sat at one table with

others from outside their respective

departments, to consider a problem

together and discuss possible solutions.

On a scale ranging from 1 (= excellent)

to 4 (= satisfactory), participants to the

“This type of training enables people to streamline processes themselves. Lean Management projects

are the starting points from where lean management will grow throughout the whole company.”

Dr. med. Hank Schiffers

Director Lean Europe, Stryker Corp.

training seminar seminar evaluated the

knowledge transfer with 1.1.

This success was also noticeable as the

project proceeded. Because participants

were now familiar with the specifi c

lean-management vocabulary and knew

which factors were relevant in the

concrete analysis of a process, this fi rst

training session had the added benefi t

of providing the basis for particularly

effective work in the second phase of

the project in May 2010. This is when

Stryker Lean Academy organized a

video-based analysis (ViMotion) of

various processes in the cardiac

catheter laboratory – such as preparing

patients or preparing for surgery.

Philosophy and training modules offered by Stryker Lean Academy

Founded by Dr. Hank Schiffers (MD and MBA) in 2006, Stryker Lean Academy

specializes in lean management solutions in healthcare. By April 2010, more than 300

people had participated in seminars and projects run by the academy.

The projects managed by Stryker Lean Academy/Lean Healthcare Services normally

comprise the following modules, the contents of which are adapted and combined

based on the needs of the partner clinic:

• Needs analysis involving all participants.

• Detailed video analysis of the processes (ViMotion) to identify superfl uous

processes and activities that cause excessive strain to the musculoskeletal system.

ViMotion is video-based analysis software that breaks down footage of complex

procedures, e.g. in the operating room or cardiac catheter area, into their individual

steps, allowing for a structured evaluation. This evaluation is carried out jointly with

the employees from the partner clinic.

• 1 day: Lean Academy white belt (for employees from the strategic management

level who want to become more familiar with the lean-management philosophy).

• 2-3 days: Lean Academy yellow belt (for employees from occupational groups

relevant to the processes who learn the objectives and tools of lean management

by combining theoretical training and individual simulation).

• 5 days: Lean Academy green belt (for managers from the occupational groups

relevant to the processes who will continue implementing the Lean Management

approach within a company after the end of the project) plus three months of lean

coaching on-site (continuous project support means of regular follow-ups and audits).

• Individual assistance with projects/coaching.

• Strategy-oriented consulting.

References:

• Schön-Kliniken Germany. See: Tim Braun, „Haus-Berater“,

In: FTD/medbiz, 01.08.09.

• Jura Klinik Schesslitz, 2-year report on “Lean for Hospitals”

“Structured processes help us to provide our patients with the highest level

of medical care.”

Univ.-Prof. Dr. med. Wilhelm Haverkamp

Director (interim) of the Charité Universitätsmedizin

Berlin Medical Hospital, Dept. of Cardiology

Data protection: all recording is

destroyed after the project ends

The use of video analysis was carefully

prepared. Participants agreed early on

to use a practical procedure that would

give no one cause for concern: all

footage would be irreversibly destroyed

following analysis so that it could not be

reviewed or fall into the wrong hands. In

addition, the records associated with the

individual video sequences did not

include the names of any of the

employees. All edited parts were made

anonymous in the presence of the

employees, so it will not be possible to

identify individuals later on.

As a result, the records provide detailed

information on weaknesses and

problems identifi ed during the project,

but not the names of the employees

involved. This concept was approved by

the Charité’s Works Council and Data

Protection Offi cer, and assessed very

positively by all participants. The Works

Council immediately saw the potential in

the innovative tool for revealing

procedures that posed hazards to

people’s health and chose to support

the project.

Filming with a conventional video

camera was smoothly integrated into

the regular working procedures in the

cardiac catheter laboratory: an

employee from the Stryker Lean

Academy simply followed the various

employees and fi lmed everything they

did. This alone produced around 45

minutes of footage. This was followed

by intense dicussions to evaluate and

analyze the video sequences. Despite

the additional work created by the pilot

project, the employees involved were all

highly motivated.

Thomas Mewes

Deputy Head of Nursing

Care in the cardiac

catheter laboratory

“Once the video camera started, I

became more aware of what I was

doing. While I was being fi lmed, I was

already thinking about how we could

improve the process design.”

The Stryker Lean Academy is quite right

to attach great importance to on the

involvement of all employees working

on the processes under scrutiny:

unfi ltered criticism from outsiders puts

most people on the defensive and rarely

leads to constructive solutions. On the

other hand, making sure everyone is

involved to jointly analyze the problems

creates trust and motivates people to

refl ect critically and professionally on

what they do.

Anna Senz

Head of Nursing Care in

the cardiac catheter

laboratory

“The training made me aware that only

we, the employees, can recognize and

increase the effi ciency of procedures

that we have established.

It was great to have management

entrust us with the task of fi nding

ways to improve processes. The video

analyses made various procedures

transparent and easy to follow for

all participants.”

ViMotion offered ideas for more

ergonomic and cost-effective

procedures

Accordingly, group participants

repeatedly analyzed the video

sequences and discussed their

observations, which were immediately

converted into concrete solution

proposals. In so doing, all employees –

including ward nurses, head physicians,

senior physicians, and the cardiac

catheter laboratory’s functional staff

– identifi ed procedures and movements

that are very likely to cause physical

discomfort (e. g. back pain) – such as

bending down and turning

simultaneously under strain or lifting

heavy objects in the wrong way.

“When jointly analyzing the video footage, everyone saw something that could be improved.

The lean project has given us many valuable ideas.”

Matthias Wiemann

Head Project Manager, project manager for improvements to

cardiac catheters at Charité’s CVK Cardiology Clinic

In view of the fact that back pain is the

number-one cause of staff absence in

hospitals, these observations produced

valuable ideas to improve working

procedures: 16 of these observations

related to improvements that could be

implemented quickly (“quick wins”),

some of which were even implemented

during the two days of ViMotion

analysis, while others were integrated

into the main Charité project. Some 30

observations related to opportunities for

improvement that should be possible to

implement in the short to medium term.

In addition while analyzing the video

sequences, employees discovered some

50 ergonomic details that need to be

addressed for occupational safety reasons

to reduce the physical strain on staff.

Gerhard-Peter Schulz

Project Manager for the

Charité’s Main Works

Council for the

“ProFu – Cardiac Catheter

Laboratories” project

“In my view, the project, which was

carried out in both the CVK and the

CCM cardiac catheter laboratories to

improve processes, revealed fl aws in

task organization and thus shows ways

of improving them, reducing

unnecessary strain on workers,

promoting motivation and commitment,

and increasing patient satisfaction.”

A lot of time wasted on

unnecessary movement by

operations personnel

Apart from the occupational safety

aspects, the ViMotion analysis also

brought commercially ineffi cient working

procedures brought to light

commercially. For example, employees

recognized the need to improve the

organization of materials. The analyses

clearly showed how much time the

cardiac catheter staff spent spent

performing non-value added tasks, e. g.

when required items are stored in two

different places, so each item has to be

individually located and transported

although they are needed together as a

set. In the meantime, the employees in

the cardiac catheter laboratory have

worked out three separate concepts for

improving the organization of materials.

They are currently discussing and

testing them to see which of these three

proposals is best suited to keep all

materials ready at hand and to shorten

paths to the patient, without creating

cumbersome storage quantities.

Based on the ViMotion analysis, the

project managers from Stryker Lean

Academy analyzed the actual savings

potential that could be tapped by

preparing the cardiac catheter room as

well as the patients to implanting a

defi brillator (ICD). With regard to the

preparation of the catheter room

(a process that previously took

26.5 minutes), a conservative forecast

showed that 30% of the time required

could easily be saved through better

process management and organization

of materials. The time that could be

saved by preparing patients was about

20%. With 250 ICD implants every year,

this means that the simplest of measures

could free up 46 hours of cardiac

catheter time every year. This time would

then be available for more surgery.

Potential to raise revenue by more

than EUR 300,000 with just one

procedure

The cardiac catheter laboratory could

therefore carry out 16 additional ICD

implants every year in these 46 hours

(total time for the process = 2.75 hours)

and so generate more than EUR 300,000

of extra revenue. The investment

required to generate this extra revenue

is in the single-digit percentage range

and no additional work would be

required. As demand from patients for

ICD implants is very high at Charité, the

cardiac catheter laboratory could

increase the number of these operations

as well as reduce waiting times and

improve patient satisfaction – after all,

these are patients suffering from

life-threatening cardiac arrhythmia.

As the procedures for getting the cardiac

catheter room and the patient ready are

similar to all treatments provided in the

cardiac catheter laboratory, these

calculations can basically be applied to

“Direct technical communication with project participants is a decisive factor

contributing to the success of our projects.”

Alexander Conz

Manager Lean Healthcare Solutions GSA, Stryker GmbH & Co. KG

all operations in the cardiac catheter

laboratory. Based on the saving potential

(expressed as a percentage) per

operation, the capacity freed up in the

cardiac catheter laboratory that

performs 3,000 procedures annually

would total 560 hours. In these 560

hours, the cardiac catheter laboratory

could carry out additional operations

generating an additional revenue of

more than EUR 2.5 million. This

projected additional revenue would also

require only relatively small investments

and no additional staff.

Stryker Lean Academy Coaches are

experts in different medical fi elds

These results speak for themselves

themselves. The basis of these results is

the concept behind the pilot project and

the criterion for its success, namely

empowering all participants to be more

aware of processes and to evaluate

them in accordance with lean

management principles. Another factor

contributing to success was the Stryker

Lean Academy team’s in-depth

understanding of the hospital sector and

the specialized medical background of

its consultants – certainly not a given in

the consulting fi eld, particularly in the

healthcare sector .

The Charité’s management now wants

the initial project implemented in the

cardiac catheter laboratory of the CVK

Cardiology Department to be the

starting point for disseminating Lean

Management projects throughout the

whole organization. Because project

participants have learned how to deal

with Lean Management tools not all of

the future projects will require external

consulting. An ongoing dependence on

consultants also contradicts the Stryker

Lean Academy philosophy: Consultancy

is not about promoting an ever growing

need for more consultancy, but about

empowering hospital employees so they

themseves are able to make their

processes leaner, more effi cient and

more patient-friendly.

www.charite.de

www.stryker.de

Charité Campus Virchow-Klinikum (CVK)

Augustenburger Platz 1

D- 13353 Berlin

Phone +49 30 450 - 50

www.charite.de

4 Wolfgang Hirn, Dietmar Student: “We have quality problems”. In Manager Magazin 7.2001

Authors

Dr. med. Wolfram von Pannwitz*

Dr. med. Hank Schiffers**

Prof. Dr. med. Wilhelm Haverkamp*

Matthias Wiemann*

Alexander Conz**

* Charité – Universitätsmedizin Berlin

** Stryker Lean Academy

GermanyStryker GmbH & Co. KGDr.-Homer-Stryker-Platz 147228 DuisburgPhone + 49 2065 837-0Fax + 49 2065 837-837www.stryker.de

AustriaStryker GmbHEuroplaza Gebäude G Am Euro Platz 2 1120 ViennaPhone +43 1 813 2000 Fax +43 1 813 1616

SwitzerlandStryker Osteonics SA Niederlassung SelzachDr. Homer Stryker Strasse 12545 Selzach/SO Phone +41 32 641 6 950Fax +41 32 641 6 955

Joint Replacements

Trauma

Spine

Leibinger Micro Implants

Biologics

Instruments

Interventional Pain

Navigation

Endoscopy

i-Suite OP

Patient Handling Equipment

EMS Equipment

© 2010 Stryker CorporationAlle Rechte vorbehalten. Das Stryker Logo ist ein eingetragenes Warenzeichen. Stryker behält sich das Recht vor, alle oder einen Teil seiner Produkte zu modifi zieren, um höchstmögliche Qualität zu gewährleisten. Gedruckt in Deutschland.

HCS-TLA-002Artikel-Nr.: HCS-TLA-002Stand: August 2010