The Quality-Cost Connection

Is your organization thinking lean?

Applying lean techniques to health care

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

The manufacturing industry has been using lean techniques for several years to improve productivity, eliminate waste, improve the quality of their products, and lower costs.

Now these techniques are being applied to health care processes. Some quality specialists view process improvement models such as plan-do-check-act and Kaizen to be synonymous with lean thinking since the goals are similar — reduce costs, improve quality, and decrease cycle time.

Basic principles

The basic principles of lean thinking are:

• Eliminate waste (retain only value-added activities).

• Concentrate on improving value-added activities.

• Respond to the voice of the customer.

• Optimize processes across the organization.

A primary concept of lean thinking is that all actions and resources of a health care organization should be focused on creating value for its customers.

Any action or resource expenditure that cannot be associated with this goal is regarded as waste and should be eliminated. It is helpful to visualize customers pulling value from the company. This pulling action extends throughout the organization and beyond to suppliers and other external organizations.

Health care organizations that have adopted lean thinking establish strategic goals and performance measures expressed in terms of value added, thereby defining the customer’s perception of value.

The fundamental objective of lean thinking is to provide perfect value to the customer through a perfect value creation process that has zero waste. Another view is that everything done in a health care organization should add to the value of the services provided to patients, their families, and other customers.

Some activities are of obvious value (for example, diagnostic testing), while others seem far removed (for example, clerical services).

However, inefficiencies in clerical activities may detract from the organization’s ability to provide excellent patient care. Lean thinking encourages viewing every activity to assure it is supporting a customer, regardless of whether the support is direct or indirect.

To translate this concept to health care, management needs to shift its focus from optimizing separate tasks or activities to optimizing the flow of an entire process or group of linked processes.

Value stream mapping

The goal is to eliminate waste along the entire value stream of a process, instead of improving just the individual steps.

In lean thinking, the value stream is depicted as a process map showing how tasks and information flow from beginning to end. Value stream mapping provides the organization with an understanding of the current state so that a future, desired state can be developed.

The simplest versions of lean thinking involve little more than a quick look at a process followed by some immediate changes based mainly on subjective decisions.

While this produces change very quickly, long-lasting performance improvement is unlikely. At the other extreme is a massive data collection effort that includes a comprehensive analysis of process flow.

This can take several months or even years to complete before any actual changes are made. The ideal use of lean thinking is somewhere between these two extremes. It is critical to do enough data collection and process analysis to improve the process based on facts, not opinions. The amount of data required will depend on the nature and condition of the processes.

Optimizing the process flow comes from having the right data and knowing how to use them.

Value-added activities are those steps in a process that contribute to the organization’s overall goals and business objectives.

Fundamentally, going lean is a process improvement methodology that involves two primary steps:

1. Analyze the steps of the process to determine which steps add value and which do not.

This involves asking questions such as:

• Does this step create value for the customer?

• Is it capable of producing a good result every time?

• Is it able to produce the right result at the right time?

• Is the capacity adequate so that wait time is not excessive — or is there too much capacity?

2. Link the value-added steps to optimize process flow and eliminate the unnecessary steps.

This involves asking questions such as:

• Do all the steps in the process occur in a tight sequence with little waiting? Does the information flow smoothly?

• Does each step occur only at the command of the next downstream step, within the time available?

• Are unnecessary variations removed and the workload levelled?

While lean thinking may at first appear to be a process improvement model that is only applicable to manufacturing, it is being applied successfully in health care organizations.

Often, lean thinking is a natural complement to Six Sigma. For example, the data gathered in the analysis of process flow can be used to identify high-priority/high-impact areas for Six Sigma projects.

In a lean enterprise, lean principles and practices (e.g., pull, flow, waste minimization, etc.) are implemented in all processes. The processes are aligned horizontally along the customer value stream.

This alignment starts with defining customer value and translating this into process requirement definitions.

These definitions provide the basis for process design, involving customers and key suppliers.

Lean thinking can be used to improve health care quality, regardless of whether senior leaders have committed to becoming a lean enterprise. For example, when improving a patient care process, the improvement team can ask: "What matters to patients? Their families?" The answers to these questions should be sought from patients and their families and not answered just by the improvement team members.

Next, the team can evaluate the current process to determine how well it is meeting customer needs. Employees should be made aware that nothing is sacred.

If a process is causing problems for customers, it will be changed to make it work better. If a particular approach isn’t working as well as it used to, it will be revised. If external factors (e.g., regulations, payment schemes, etc.) change, the job of individuals may be altered.

The "because we’ve always done it that way" excuse is not acceptable in explaining why a function or task shouldn’t be changed or eliminated.

Another lean technique for examining a process is to walk through it as though you were the customer, asking questions such as: How does it look from the patient’s point of view? What is the purpose of this process? How does it help us serve patient needs?

If you find things that are clearly broken, the next step is to gather enough understanding of the process to enable you to redesign or change the process.

The people involved in the process should be involved in validating what is going on, testing the redesign, agreeing to measures by which you can check that the new process is working and, of course, implement any changes.

Lean techniques are a form of systems thinking combined with the belief that any process can be improved.

However, prior to making any change, the "what and why" of current performance is established based on customer needs.

The purpose of any health care organization boils down to getting and keeping customers. A systems view of an organization focuses on what needs to be done to fulfill this purpose.