For the last decades many organizations started using Lean as their major business strategy for organizing and improving their operational activities. Results in manufacturing have been very good, but nowadays also service and office environments start to realize that the Toyota Production System, which is the basis of Lean, is a universal approach. Healthcare institutions, especially in the UK and the US, are also already applying lean principles. This paper describes how one department from the Ghent University Hospital in Belgium started to implement lean, resulting in significant performance improvements. After a brief discussion on the different elements of the TPS, we will show how they were adapted and applied in a service environment.
Lean Thinking is probably the most emerging improvement strategy the last decades, and this on a global scale. Based on the Toyota Production System and its principles, the first applications and successes were shown by Womack and Jones. Many publications have since then described the Toyota Production System and its tools in great detail. The overall goal is to have the best quality in the shortest lead time at the lowest cost through improving the flow by eliminating non value added activities, also called ‘waste’.
The TPS is made out of several pillars as depicted in Figure 1.
As with Toyota, the first implementations of Lean Thinking were in manufacturing environments, while later it became clear that also office and service processes could benefit from the lean approach. In that perspective, some important achievements were made in applying lean principles and tools in healthcare, especially in the US and the UK.
Since a few years also in Belgium and the Netherlands, some hospitals are discovering Lean and the successes that have been obtained abroad. This has motivated them to make the first steps. In Belgium, the University Hospital in Ghent has been taking a pioneer role. This paper describes the finding of our exploratory research: how can different elements of TPS be adopted for implementation in a service/healthcare environment and does this lead to significant improvements. The main focus of this research was in one pilot area: the Dermatology Department.
2. The Dermatology Department and the need for Lean
Although already nationally and internationally being recognized as a highly regarded academic department with several expert faculty, high impact scientific research projects and publications, the Department has a vision that all of this could be done in a better, more structured way with a clear patient focus.
The staff realized that a necessary condition for achieving this vision was having clear, standardized and sound operational processes. One major component of the burning platform for change was that patients were experiencing long waiting times for consultations, poor punctuality, lack of communication of relevant information at the appropriate time and many difficulties to reach the department by phone.
Therefore Lean was chosen as the main strategy to achieve this vision, given the focus in Lean on customer/patient value, well designed processes and value streams and last but not least, a paradigm shift and a lasting culture change.
3. Implementation of Lean Tools
3.1 Correctly specify ‘Value’ for the customer – Identify the value stream
As Womack and Jones describe in their 5 steps of implementing Lean Thinking: you should start with correctly specifying ‘value’ for the customer. Although frequently forgotten and not always easy to do, this is a critical step. Too often people jump straight to the reduction or elimination of waste, however this cannot be done in a very effective without this first step. Mathematically speaking we can say that ‘Waste= 1 – Value’, so the full extent of what waste is, only becomes clear after we define value.
A cross functional team of representatives of the different roles within the department came to this definition of ‘value’:
- A patient expects top quality medical care, supported by evidence based medicine.
- A patient expects a streamlined process, without waiting times and with punctual appointments.
- A patient expects to be satisfied with the complete value stream.
Based on these expectations concrete objectives were determined (Table 1).
Table 1: Objectives for the lean implementation
|Cancer patients||Regular patients|
|Reducing waiting times for appointments||< 1 week||< 2 weeks|
|Improve punctuality on the day of the appointment||80% within 5 minutes||90% within 5 minutes|
|Increase number of patients per doctor||260 per week|
|Increase Patient Satisfaction (based on large scale survey)||
The value stream represents how value is currently created throughout the department. Typically it can be easily observed that not everything that happens is value. There were numerous examples of the different types of waste.
Some examples are mentioned in Table 2. Immediate countermeasures were identified and implemented by the people on the floor.
The current state observations also showed that performance on the KPIs needed a drastic improvement. Current values are shown in Table 3.
Table 2: Examples of some types of waste in the Dermatology Department
Type of Waste
|Overprocessing||Results of allergy tests are first written on paper, then typed into a computer and on top of that, copied for the archive.||Only one entry of the data in the electronic filing system, accessible for all authorized personnel|
|Transport||Beds of patients were transported to the specialist creating congestion and chaos in the hallways.||The specialist will go to the patients. Only patients that are mobile come to the consultation area.|
|Waiting||Unbalance in Cycle Times as the allergy doctor finishes earlier seeing the patient than the nurse who has to perform the allergy tests. This causes waiting for patients.||The doctor will already start writing the report and completing the patient file. In that case workload is better balanced and waiting times reduced.|
|Motion||Equipment needed is spread out over different rooms.||Analyse and improve the layout of the lab using spaghetti charts.|
|Talent||Not enough critical review of which tasks have to be performed by the specialist versus the nurse||An area has been setup in which the nurse can do basic work on wounds, doctors do only the more surgical work.|
Table 3: CurrentState performance
|Cancer patients||Regular patients|
|Waiting times for appointments||4 months||6 weeks|
|Punctuality on the day of the appointment||37% within 5 minutes||10% within 5 minutes|
|Patient Satisfaction (based on large scale survey)||
4.2 Implementing one piece flow in the consultation value stream
The current state value stream analysis showed that the doctors reserved about 15 minutes of time for each patient and that they were typically writing their reports of their examinations in the late afternoon/evening, after seeing all patients first. It became clear that all activities were not executed in a one piece flow fashion.
As can be imagined, beside a physical changeover (retrieving and opening each patient file) there was in this case also an important mental changeover.
As a countermeasure the consultation times were increased to 20 minutes. Hence, the writing of the report could be done immediately. Although the scheduled times per patient were increased, overall there was a reduction in time needed per patient, so extra capacity became available and more patients could be seen. This was really counter-intuitive to what people in the department were expecting. Until then, for them an increased output always had to go along with more capacity.
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4.3 Implementing load leveling (Heijunka) in the consultation value stream
4.4 Reducing variability by better matching capacity and demand
4.5 Eliminate waste and increase capacity by implementing standard work for specialists
4.6 Enabling and supporting continuous improvement with visual management, performance boards and 5S
5. Results so far and next steps
6. Conclusions and further research
If you want to know more about Lean in Healthcare or Office/Administration or Manufacturing then attend one of our training programs: Van Goubergen Lean Academy