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Lean begins to have an impact in hospital and healthcare (re) design. It originated in the manufacturing industry, developed by Toyota in Japan, just after the Second World War. In recent years it has been increasingly adopted by healthcare organisations as a means of improving efficiency, reducing costs, eliminating waste and in the design of physical layouts. Redesign projects have been implemented in numerous countries to address a wide range of problems and have been conducted with varying degrees of success. However, the overwhelming evidence, as demonstrated in a variety of publications, suggests that lean redesign and lean methods are effective. Not only has it achieved a reduction in patient length-of-stay, reduced emergency department waiting times, reduced costs, improvement in the safety and quality-of-care but has also improved physical work environments for healthcare professionals. Work environments that have incorporated work processes supporting patient-centred care have led to better facilities and better care delivery.
THE LEAN PHILOSOPHY AND HEALTHCARE
Lean compromises three concepts: People, process and design. Tools have been created and are incorporated to optimise the identified concepts. People are the most important in terms of valuing and respecting them, as lean is owned by the people who do, and understand the work. Within in the concept of process, lean provides a common sense, practised approach, which is rooted in the scientific method with the aim to eliminate waste. Within design, process transformation can be supported and accelerated through efficient design (of buildings and facilities equipment). To build a lean hospital, lean process improvement as a leadership strategy and frontline reality must precede lean architectural design. This notion needs to be embraced by leaders and managers at all levels of an organisation to ensure that lean becomes a sustainable strategy. In order for a lean programme to be successful, senior leaders need to support and buy in to the idea that lean can benefit the entire organisation.
The vast majority of applications of lean thinking in healthcare have been implemented in North America. Of all lean healthcare cases reviewed in a systematic literature review in 2009, it was found that 57% originate from North America, 29% from the United Kingdom, 4% from Australia and 9% from elsewhere. The most effective implementation of lean redesign in Australia has been at Adelaide’s Flinders Medical Centre. The Flinders Medical Centre implementation of lean (which they called Redesigning Care) began in November 2003 and has resulted in a 50% increase in the number of patients seen per day in their Emergency Department. This has coincided with a dramatic decrease in the number of patients who leave without being seen in the ED. The length of stay for medical patients admitted via the ED has also fallen by such degree that more than 15,000 bed-days have been saved since the implementation of the Redesigning Care programme, which would produce a significant financial gain.
Using lean in terms of looking at built assets is rare. However, the Virginia Mason Institute claims to have saved 25,000 square feet and capital receipts of AUS$11 million by using lean principles. The concept of lean is a relatively new approach to the Middle East, although outside health there is evidence that architects and engineers are starting to embrace the idea. Several examples of this type of approach exist and include Etihad Rail and Al Falah Housing in Abu Dhabi, UAE. Recently in Saudi Arabia, the Ministry of Health has launched a health improvement initiative using lean principles.
In some ways parts of the Middle East are blessed with a high number of new and modern hospitals and their layouts may not require substantial redesign. However, even modern buildings could benefit from a lean approach. Conversely, as articulated by the Senior Vice President of Thedacare, North America (a well-known lean healthcare facility), there is no such thing as an architect or construction firm that can build you a lean hospital. Lean is not a building, it comes from within. This notion is based on the belief in having respect for people and seeing people as the drivers of Lean thinking, which is part of the Lean philosphy.
THE TASMANIAN CONTEXT
In Tasmania, Australia, lean has been used in public hospitals, and in the south of the state the former Innovation and Redesign Unit was responsible for this work through a hospital-wide reform programme. This programme aimed to empower staff to improve their local work environment by engaging with each other and learning new skills that enable improvements to patient safety, quality-of-care delivery, staff satisfaction and communication. Strategically, this was achieved on two fronts: The Patient Centred Care Module and the Consistent Ward Module.
It is some of the results of this last module, which will be featured in this article. The module was based on the United Kingdom National Health Services’ (NHS) Productive Ward and aimed to reduce the amount of time healthcare professionals had to spend on tasks that take them away from the bedside (direct patient care). The module involved the question of how health professionals can reduce tasks such as unnecessary walking (motion), looking for equipment, searching for information (waste) and in return spending more time at the bedside. Within the NHS this was called ‘releasing time to care’.
There are eight known types of waste:
1. Overproduction, producing more than what the patient needs
2. Inventory – this often refers to materials and one of the examples is an overstock of, or ordering excess material because the supply is unreliable
3. Waiting – refers to a patient or material waiting, instead of moving at the pace of customer demand. Examples are: waiting in queues at the surgery, waiting for tests
4. Not using talent, not using people to the best of their unique abilities
5. Transportation, unnecessary transporting of patients, medications, specimens or supplies. An example of this includes moving a patient to an inpatient bed for review at post-op ward round and then to another ward for discharge
6. Defects, work that contains errors or lacks something of value. For example, cost of patient readmissions
7. Staff movement or motion – unnecessary movement in the workplace relating to layout and organisation
8. Unnecessary processing, ambiguous redundant work and non-essential paperwork that adds no value from a patient perspective. For example, three different healthcare professionals might ask a patient the same or similar questions in relation to their illness.
ELIMINATING WASTE AND THE USE OF TOOLS
Managing and eliminating the eight wastes are key to streamlining a system and running clinical areas such as wards more efficiently for staff and patients. The lean concept incorporates several tools to support this process such as visual management, 5S and process mapping, which can be used to support waste reduction. The Consistent Ward module had a straightforward approach to removing waste. To visualise waste, process mapping and the use of spaghetti diagrams were part of the utilised lean strategy in Southern Tasmania. The spaghetti diagram was used as a tool to help establish the optimum layout for the department or clinical area, based on observations of the distances travelled by staff and/ or products. Spaghetti diagrams are useful in exposing inefficient layouts and can identify large distances travelled between key steps.
The tool was used by drawing a diagram of the floor plan of the area that was under evaluation. Lines were drawn on this diagram to map the flow of movement. The established diagram was assessed and used in helping to redesign the process. To identify unnecessary movements, the lines across the area were analysed. This led to a decision to bring two areas closer together to optimise the flow. By analysing the spaghetti map, it had become clear that an enormous amount of unnecessary movement of staff to a storeroom located outside the clinical area of the Royal Hobart Hospital was occurring. The design of healthcare environments should aim to provide infrastructure that will support healthcare professionals.
It took staff valuable time to collect required materials used for care delivery. This was caused not only by the distance travelled, but also by an ability to easily find the location of a certain item within the room. Based on this information, it was decided to move the storeroom to the middle of the clinical area. The spaghetti diagram, in other words, was a mapping tool for ‘Lean Process Improvement’. It provided a useful visual overview of the geography of the process.
Further work was undertaken by sorting, finding a set place for all materials and by clearly marking its location. This process was repeated for most clinical areas within the hospital setting. Image one shows a storage room before and image two shows the same storage room after the change process had been completed. The efficiency of these changes was tested by timing a member of staff prior to the changes to find certain supplies and this was repeated after the changes had been implemented. A significant reduction in time to find the required items was found. The tool used to create and sustain these changes was the 5S. The 5S stands for Sort, Shine, Set, Standardise and Sustain. It involves a process to ensure areas are systematically kept clean and organised, which assures staff and patient safety. Vital to this is the concept that standardisation of work is key.
The Consistent Ward module has demonstrated a change in culture within those areas in the organisation that participated, and showed cost savings. These cost savings have predominantly been shown when a unit actively participates in utilising the ‘5S’. It encourages a commitment from staff to learn technical skills to lead change within their area. This in turn builds adaptive capacity for change within the organisation by way of consultation and engagement of staff, working on the coalface, that directly own and lead the change.
This biggest improvements are not only to the organisation of the ward environment, but to the ability of staff to decrease time spent during their shift searching for equipment or products, allowing them to spend more time ‘caring’ for their patients. From a financial perspective, gains in cost savings have been demonstrated across hospitals within these storage areas by: Relocating storage rooms, decreasing the amount of stock held, utilising and maintaining the revised levels appropriately and less staff time spent searching for items.
Lean thinking brings together several strings of process improvement. It starts by defining the purpose of the process value for patient and staff and then redesigns the process to deliver that value. Mapping is the process of observing and understanding the current condition and drawing a map, using spaghetti diagrams, which in turn becomes a blue print for lean healthcare implementation. It provides a view of a process that has been targeted for improvement.
Using the lean concept in healthcare can lead to many positive results. This article has focussed on a practical example used within the Tasmanian healthcare setting. In making relatively simple adjustments to storerooms, it became clear that motion time was reduced, and cost savings were achieved, allowing more time to care for patients. Many other examples are readily available to prove that lean has a place in healthcare and hospital design.
References available on request (firstname.lastname@example.org)