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 dont 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 its 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
couldnt 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
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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.
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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 didnt 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.


Hospital Food Services
Hospital food, what comes to mind when you hear
those words? For many its the thought of cold
coffee, poor presentation, bad service, served at
times when you dont 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 hospitals 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 didnt 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 didnt 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 groups 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 laboratorys 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 CBCs 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.

CBC Average Accession To Result TAT
0
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7
Week of
M
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s

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.

Differential TAT
0
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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%.
Count of Result Method
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9 10 11 12 13 14
SAPH2
SAPH1
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HMX1
GENS1
shift (All) PtOrd (All) TestCode NEU
Count of ResultM
WEEK ReceiveDate
ResultM

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 Laboratorys 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 doesnt feel like I
am doing the same amount of work as before. and
I dont 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.



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 isnt 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 - thats 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
thats 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 isnt 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 teams
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.


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 didnt have a home. As well, their location was
the basement - it was out of site and it was
considered less clean and maybe it didnt 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 didnt 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 5Ss
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 teams first priority was to clear out a room that
was approximately 20x40 with about 60ft 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 5Sd.
The results have been astounding. In an afternoon,
they completed their sorting and freed up over 600ft
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 didnt 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 didnt 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 others, 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 cant 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 werent 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!

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