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Lean th inking acr a cros osss a ho h ospi sp ital: al : redesigning care at the: Flinders Medical Centre. By: Be Be n- Tovim Tovim,, Dav Da vid I.,Bassha I .,Bassham m , Jane E .,Bolch, D enise,Martin, Margaret A.,Dougherty, Melissa,Szwarcbord, Michael Publication: Aus Austtral raliian He Heal alth th Rev Rev ie iew w Date: Thu Thursday, rsday, Febru Fe bruary ary 1 2007
Abstra Abstra ct Lean thinking is a method for orga nising comple x produ produc ct ion ion processes processes so as a s to encourage encourage flow flow a nd reduce reduce wa ste. W hile ile the prin princi ciples ples of lean thin hi nk ing ing w ere dev de veloped in the manufact manufact uring uring sector, sector, there is in creasing reasing interest interest in its app ap plic li cation ation in hea lth ca ca re. re. This case case his h istory tory do do cuments cuments the introdu introductio ction n and develop developm ment en t of Redesign Redesignin ing g C are, a lea n thinking thinking -base -based d p rogr og ra m to redesign ca ca re processes processes across a tea ching ching general gene ral hospita hospital. l. Rede Redesi signing gning Care C are has has produ produ ce ced d substantial benefi bene fits ts ov o ver the first first tw o-and-a-half o-and-a-half years of o f its imp imp lementation, ementatio n, making care care both safer safe r and more a ccess ccessib ible le . Redesign Redesignin ing g C are has has not been aimed aimed at changin chang ing g the spe cifics cifics of clin clin ica ica l practice. practice . Rath Rathe e r, it has ha s bee n con con cerned w ith impr imp rov ing the flo flow of patients of patients t hroug hroug h clin clin ical ical and an d other oth er syst sys tems . C oncep onceptts that emerged emerged in the manufac manu factt uring sector sector have ha ve been readily re adily translatab translatab le into into he alth care. care. Lean Lea n thinking thinking ma y pla pla y an important role role in the reform reform of health he alth care in Aust Austrra lia and an d e lsew lsew here. Aust Aust H ealth ealth Re v 2007: 2007: 31 (1): 10-15 ********** THI THI S PAPE PAPER R DESCRI BE S the the int rodu ction ction and a nd early results of the the Redesigning Care Program at the Flinders Medical Centre. Redesig Redesign n ing ing C are are explici explicitly tly appli app lies es lean th inking inking (1) to health ca re. Lean thinking is a codific cod ificat ation ion of o f man man ufacturing ufacturing te chn chn iques pioneer pioneered ed b y the To yota Motor Moto r Com Co mpany pan y. During During a la rge scale
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analysis of moto r manu fa cture rs, (2 ) the produ ction proces ses developed by the Toyota Motor Company were identified as being so different from those of other large car-maAnd kers as to constitute a Cancel Download Print new manufact uring methodology, re ified b y the authors as lean thinking.
Lean thinking and redesigning care Lean thinking is an atte mpt to correct the delays and wasteful reduplications that chara cterise man y mass product ion processes. The issues have rema ined essentia lly un changed sin ce Henry Ford developed the mass production methodology in the 1920's. In order to produce large numbers of differing kinds of vehicles, Fo rd arranged his fabricatio n machinery into production villages dedicated to specific functions. The inevitable hiccups in p roduction within and between production villages were managed by mainta in ing large buffe rs of parts at every stage in production. Variations in customer demand were managed by creating banks of finished goods that were forced on dealers (and w hich, when unsold, w ere moved by means of special p romotions ). The costs o f holding large a mounts of unfinished goods w ere contained by reducing the cost per production step b y any means possible , the buffer sto cks managing any res ultant dela ys in production . Nowadays, this may mean producing components i n widely separated lo cations . Lean thinking facilitates moving from mass to flow product ion. Flow production a ims to d ramatically decrease the time taken to p roduce goods by arranging the re levant machinery in p rocess sequences, rapidly changing a machine's w orking p rocess to match changing process requirements so that goods can be made in response to customer de mand rather than to a prearranged production schedule . C osts are conta ined b y minimising buffer s tocks, by rapidly identifying and avoiding w asteful errors in production, and by a voiding wasteful over-prod uction a nd over-processing. These
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latter steps also lead to dramatic impro vements in the quality o f the goods produced.
Cancel Download And Printion of lean thinking The basic p rincip les underlying the implementat
are laid out in the Box. Interest is grow ing in the potential utility of lean th in king in health care, (3 ,4) where the need to improve the flow of patients through hospitals and health servi ces is beco ming increasingl y urgent. Redesig ning Care is using lean thin king to imp rove f low and redu ce waste in co re clin ica l and support services across a whole hospital . It is not, however, concerned w ith attempting to influence the pro fessional content of clinical encounte rs. That is deemed to be outsi de the s cope o f the program, which is primarily concerned with flow and logisti cs. This case history ma y be of some interest to othe rs seeking to transform their hospital or health service using similar methods. The key principles of lean thinking
* Spec ify the value des ired b y the customer * Identify the value stream for each product or service providing that value, and challenge all the wasted steps * Make the product or service flow continuously * Introduce pull between all the steps w here cont inuous flow is impossible * Manage towa rds perfection so that the n umbe r o f steps and the amount of time and information transfer needed to serve the custo mer continual ly fall
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The Flinders Medica l Centre is a 500-bed teaching general hospital in t he southern suburbs of Adelaide. Flinders is a " cradle-to-gra ve" institution, providing a co mplete range of secondar y and tert iary services to a populat ion o f a round 300 000. It is the largest member of a de-facto consortiu m o f hospital and co mmunity health service providers that also includes a smaller general hospita l and a community hospital. The Flinders Medical Centre is the prima ry regional provider of time urgent, comp lex ca re of all kinds . The Emergency Department is busy, seeing some 50 000 patients per year, o f whom around 40% require hospital admissio n. Sequence of events By mid 2 003, the Flinders Medical Centre Emergen cy Department had become so congested that patients were regularly overflowing into the nearb y recovery area o f the operating theatre s uite, disrupting the w ork of both the Eme rgency Department an d the Division of Surgery. Ca ncellations of ele ctive w ork w ere pervasive, surgical training s chemes were under scrutiny, the sa fety of care in the Emergency Department was becoming compromised, and high levels of staff turnover w ere undermining the viability of key clinical services. These difficulties had not arisen suddenly; nor w ere they a consequence of unusual leve ls of de mand. Fl inders w as struggling to fulf il the predictable de mands of the population served. The clin ical staff at the Flin ders Medical Centre are energetic and well motivated and had adopted standard practices to diminish congest ion , (5) but without sustained bene fit. W hat w as needed was to do something that the staff did not yet know how to do. The then-hospital board agreed to p rovide non-operational fu nds to support a program o f hospital redesign, the e xact nature o f w hich was yet to be clarified.
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Two of us (DBT and MD) had started working w ith the E mergency Department staff analysing why safe and sustainable care wa s so hard to provide. Mak ing little headway, we came across a description of proces s mapping on a National Health Se rvice (NHS) Modernisation Agen cy website. (6 ) In lean th inkin g te rms, the process is the end-to-end sequence of steps required to transfo rm a raw material to a fin ished product (1) and process mapping is the name given to the creation o f an end -to -end flow diagram of the steps involved. Taking the patient's symptoms (1) at the point of pres entation as the "raw material" and the patient's journe y from arriva l th rough to ex it fro m the Emergenc y Department as the "product", w e resolved to map the steps involved in the patient journe y throug h t he Emergenc y Department. W e gathered a large multidisciplina ry group of Emergency Department sta ff and started to work our way through the journeys of patients who were either discha rged di rectly fro m the Emergency Department, or w ho needed admitt ing to hospital. The care processes involved we re described as the staff saw them. Seve ral sessions w ere needed to do cument the steps invo lved in the patien t journe y through the department. The mapping s essions had a profound impact on a ll invo lved. They crea ted a shared aw areness of how chaotic the care pro ces ses had become, and generated support to change processes within the Emergency Department irrespective of what was being done elsewhere in the hospital. How exactly to do th is w as still not clear, and the search fo r an imp rovement model began in earnest. A small group of sen ior staff made a brief visit to London, hosted by the NHS Modern isa tion Agency (sin ce dissolved). The itinera ry included visits to a numbe r o f hosp itals, and d iscussions with Moder nisation Agency staff, one of w hom also spent severa l days in Adelaide advising the hospital on the structure of an improvement program.
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The United Kingdom visit demonstrated that real changes could be made to the organisation of care within emergency departments, and that those changesCancel could have a profound impact on congestion Download And Print within those departments . Mode rnisa tion Agency sta ff also exposed the Flinders group to the con cepts of lean th inking. Follow ing the t rip to the U K, the D irector of the Emergency Department proposed a radical restructuring of the w ay patients flow ed through the Emergency Department at the Flinders Medical C entre. The mapp ing had de monstrated that attempt ing to prio ritise care by means of the Aust ralasian Triage Scale , a five point mea sure of pat ient a cu ity, materially contr ibuted to the co mp lex ity of patient a llocations w ithin the department. The sta ff w ere cont inually attempting to res pond to the distress of pat ients who were "bumped" o ut of order fro m the ir place in the notiona l q ueue when a patient w ho arrived after them was seen before them because the y were in a d ifferent t riage category. Ad hoc and hard to manage strategies we re being used to try to push patients th rough when the build -up o f " bumped" patients became e xcessive . The new flow s involved breaking away from using the t riage s core as a method for prioritising care w ithin the department. Instead, patients would be as sesse d by a t riage nurse w ho, w hile a llocating a triage score , w ould also indicate w hether in h is or her judgment the patient w as likely to be ad mitted to hospital or to return home dire ctly from the department. Each stream of patients (likely to be discha rged, likely to be ad mitted) was to be aligned w ith a separate team of nurses and docto rs in specif ic areas of t he department. In the absence of a threat to l ife and limb , patients w ere to be s een in order of a rri val . Initially, this w as only if they w ere likely to go home, but subsequently, the p roposal wa s w idened to include a ll adult patients. Staf f received brief orientation to "strea ming", as the new processes came to be described, and it was initiated tow ards the end of November 200 3. The impact was immediate . At the end o f the first
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day, there was a disce rnible les sening of the chaos w ithin t he department, and this sense of increased cont rol has continued. Streaming has been well supported b y the staff Cancel Download And Printand has been mainta ined continuousl y since its introd uction. A clear indi cation of the in creas ed acceptability of the care provided was the immed iate ha lving of the nu mbers of patients leaving the department without completing their care . "D id -not-waits" as a percentage of arrivals fell from 7% of a ll arrivals to just over 3% and have been maintained at that le vel . Stream ing also de creased congestion by de creasing the overall time patients spent in the department. The a verage time that patients spend in the department was reduced by 48 minu tes in the first year a fter imp lementat ion (bring ing the a verage time spent in the depa rtment from 5.7 hours dow n to 5 hours). The next year saw a 10% increase in t he nu mbers of patients attending the department, but the decrease in average time in the department was not only mainta ined, it w as further redu ced by 6 minu tes. Lean thinking across the hospital The concepts behind st rea ming derive d ire ctly from lean thin king. The redes ign began with the ident ification of "patient-care fa milies". Patient-care fa milies are g roups o f patients w hose care pro cesse s overall are sufficiently sim ila r to each other, yet different from those required by other patient-care families , to be managed together. In this case, the patient-care families w ere "like ly to go ho me", and "likely to be admitted to hospital". The sum of the steps needed to complete the journe y o f ea ch patient-care fami ly is know n, in lean thinking terms , as the value stream. Mapping care processes from beginn ing to end allow ed us to "see" patient ca re families and their value s treams and to identify w asteful delays and reduplication along the journe y. Lean thinking is focused on imp ro ving flow by simplifying production processes, l ining up the steps in a value stream so that a steady production rhythm can be a chieved. In the Emergency Depar tment, reduction o f w aste and improvement in
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flow w as achie ved b y crea ting produ ction "cells" aligned w ith value streams. Ea ch cel l fo cused on a particu lar patient-ca re fam ily and completed w ork as it a rose rather than queu ing patients and the n Cancel Download And Print treating the m in batches. The early success of th is intervent ion w as sufficient to conf irm the value of testing the application of lean thinking to co re clin ica l and support services throughout the hospital. The progra m was called Redesign ing C are, and the small team o f a part-time director and three fullt ime clinical facilitators (all senio r nurses ), suppo rted b y the senior managers in the hospital, set about increasing thei r know ledge of lean thinking and de velop ing a structured approach to the implementation of lean thinking ac ross the hos pital. Initiall y, Redesigning C are programs were aligned with three broad streams of work (emergency, med ical and surgica l), each headed b y a se nior clinician and e ach w ith a sponsor from the se nior hospital execut ive. Over time, the range e xpanded to include support services, mental health , and transition to community ca re. Specific progra ms of w ork a re scoped as to the beginning and end of the patient (o r other pro cess) journeys involved, and a s coping document is ag reed to by the ke y stakeholders . Process flow mapping and tracking of real -li fe patient journe ys are then used to crea te a detailed picture of how the wo rk is done now (the cu rrent state) and to generate acceptance o f the need for change . A series of "plan-do-st udy-a ct" cycles a re then initiated based on the imp rovement opportunities that "fall out" of the mapping pro cess. The cycles a re developed an d undertaken by w ork groups of staff invo lved, with fac ilitator assistance. Ta rgets are deve loped by the groups and are monitored continuously. Formal evaluations at designated poi nts set the scene fo r the most difficult challenge of all: ma king change susta inable in the long run--making the new way the "wa y we do it rou nd he re". Lean thinking con cepts en courage health care prov iders to think about the patient journey from arrival to d ischa rge as a co mp lete
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care process rather t han as a series of dis connected steps. As staff in hospitals and health services, w e tend to be "po int optimisers", focusing on do ing the work in front o f us And a s best Cancel Download Print w e can, igno ring the impa ct that changes to a step may have on the steps on either side. A clear e xamp le was provided early on in our redesign a ctivities. W e were mapping ou t the mo vement o f pat ients through a large inpatient service when it became clear that patients trea ted within this service co mmonly spend at least half a day longe r in hospital than necessary because t hey could not be discharged w ithout a date for a crucial fo llow-up test in a hospital clinical laboratory. That laboratory was under such p res sure to per for m tes ts that it had put the fu nding for i ts re ceptionist against a new laboratory technician. The net result was that appoint ments could only be made when a laboratory s taff member was free to pick up messages left on an answe ring s ystem . Getting a ppoin tments w as very difficult, leading to delays in discharg ing patients, which in turn increased conges tion in the Emergen cy Depa rtment while new ly arrived patients w aited for a bed . Redesigning Care across the hospital Fro m its inception, Redesign ing C are was seen as a change progra m. Support for the program has bee n built by communicating the methodology and the res ults in many different ways. Important elements ha ve been "lean thinking" days in w hich the basic con cepts ha ve been int roduced to la rge numbers of staff. The re is also a more intensive program of exposure to lean th inking of staff from designated areas who will be key participants in specific progra ms of w ork. By now, hundreds of s taff across the hosp ital are invo lved in redesign activities o f one fo rm or another. A hospita l is su ch a diverse entity that it may be hard to know where to begin a program of redesign. How ever, the pressures generated by the emergency ca re of patients w ere such that they
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had to be attended to. But a hospita l is a dynamic entity. One patient cannot be admitted unless a previous patient has been discha rged.
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Initial mapping w ithin the medica l an d surgical streams indicated that care processes could commonly be separated out into those required by patients who would spend relatively short periods (up to 72 hours ) in the hospital, and those required by longer staying patients. A sho rt-stay medical-surgical wa rd of some 20 beds w as developed for the majority of patients admitted as an e mergenc y and pred icted to spend a short time in hos pital. Th is unit now accommodates a round one in fou r patients admitted to the hospita l. The staff in the medical and su rgical wards no longer ha ve to split their attention betw een the comp lex ca re needs of longer staying patients and the administrative and organisationa l tasks involved in mov ing patients rapidly th rough the hospital. The capacity ga ined by this de velop ment enabled the hospital's sma ll elective surgery progra m to return to fu ll fun ctioning. Surg ical train ing sche mes ceased to be under threat, building f urther support fo r the program. Importantly, the rate of s erious adverse e ven ts repo rted to the hospital insu rers has halved sin ce the Redesigning Care program began, and the w idespread take-up of c lini cal imp rovement progra ms a cross key clinical divis ions has also been an important cont ributor to enhanced safety across the hospital. Other important Redesigning C are initiatives ha ve included: redesigning the provision of medication at discharge, ha lving the time ta ken to pro vide that med ication; substantial changes to bed management pro cesses; and redesigning the flow of longer staying medical patients. The latter program has reduced the a verage length of stay in the la rge genera l medical s ervice by around 1 day of stay. While it has not been the primary fo cus of the Redesign ing C are progra m, in the current financial year the hospital is providing care sufficiently cost ef fe ctively to be able to direct modest savings from
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its operat ional budget into enhanced equipment replace ment and staffing. Th is is the f irst t ime in many years that this has been possible.
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Problems, conflicts and constraints The Redesigning Care Program is a major change program and as such w ill ine vitably come up against a wide variety o f difficulties. One of the mo re thought provoking of these has been the cha llenge offered to e xisting middle and s enior managers. I n gene ral, hea lth care managers are chosen fo r their p roblem solving s kil ls. The most successful excel at " fire -fighting" and enjoy the drama involved. But a basic maxim of lean thinking is not to start with a solution, but to go to the workpla ce, unde rstand how the w ork is done and look for root causes of delays and other impediments to flow . There is therefore a tension between the somew hat painstaking, bottom-up approa ch emp loyed by Redesig ning Care, and the mo re usual "command and control" p rocess adopted by health care managers who, once a prob lem has been identified, see their role as co ming up with a so lut ion that front-line staf f then have to imp lement. Early clos ure a nd starting with a solution is not confined to hospital managers. It is pervasive at every level in the health system. Lean thin king requires managers to ensure that a decis ion gets made , rather than ma ke every decision. Actin g as a fa cilitator to decis ion mak ing is not easy, and t he te mptation to regress to knee-jer k proble m solving seems ever prese nt. Discussion Patients are not cars, and providing good clin ical care invo lves compassion and empathy as w ell as cognitive and organisational skills. Acknowledging that, it is still possib le to con ceptualise patient journe ys as lengthy sequences of specific trans formative steps strung along de-facto p roduction lines spread throug hout hospitals and health services. Lean thinking is not about influencing the content of thos e moments w hen patients and staff are in contact. It
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is about giving more time fo r those mo ments, ma king them easier to perform and less prone to error, by simplifying sequences , mak ing w hat has to be Cancel done more transparent, Download And Printre moving reduplicative and unne cessary steps, and making hard-to -pe rfo rm steps easier to get right. At an operat ional level, health care p ro cesses are almost never designed end-to-end. The y e volve slow ly, each component evolvin g within its own niche or process village, and w ithout necessarily taking acco unt of the impact on steps up and dow n the line. The Flinders Medical C entre has bee n using lean thinking to ma ke a start on designing w hole sequences of care--not simply to provide the care that is right, but right first ti me, fo r the right pat ient, at the righ t p lace, and at the right time. As w e do so, the s ize of the chal lenge and the potential benefits of succes s be come clear. Redesigning C are has made a start, and it is only a start, on this important task.
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Com peting interests Cancel Download And Print The authors declare that they have n o com peting interests.
(Received 3/07/06, revised 4/09/06, accepted 1/10/06) References (1) Womack J, Jones D. Lean thinking. Banish waste and create wealth in your corporation. London: Simon and Schuster, 1996. (2) Womack J, Jones D, Roos D. The machine that changed the world. New York: Rawson Associates, 1990. (3) Reinertsen JL. In tervie w with Gary Kaplan. Qual Saf Health Care 2006; 15: 156-8. (4) Jones D, Mitchell A. Lean thinking for the NHS. London: NH S Conf ederation, 2006. (5) Bartlett J, Cameron P, Cisera M. The Victorian em ergency department colla boration. Int J Q ual Health Care 2002; 14: 463-70. (6) Nationa l and Primary Care Trust Developm ent Programme. NHS M odernisation Agency Dem and Mana gement Grou p. The Big W izard. Available at: www.na tpa ct.nhs.uk/dema nd_managem ent/wizards/big_wizard/downloa ds.php (accessed Jun 2006).
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What is known about the topic? Cancel Download And Print Lean thinking, while developed in the manu facturing sector, ap pears to be a
relevant technique fo r redesigning hospital care. What does this paper add? This paper provides a case study of the implementation of lean thinking, initially in the Emerge ncy Departm ent, an d then throughout Flinders M edical Centre. What are the implications for practitioners? Using the principles of lean thinking, practitioners are en couraged to exp lore the value that process components provide to patients. Using a participative approach, the proces ses can then be streamlined to improve p atient flow. David I Ben-Tovim , PhD, MB BS, MR CPsych, FRACNZCP, Director, Clinical Epidem iology and Re designing Ca re Units Jane E Bassham , RN, BN, Clinical Facilitator, Re designing Care Denise Bolch, RN, RM, BN, MBA, Deputy Di rector, Redes igning Care M argaret A M artin, RN, DipApp Sc(Nu rsing), BN, M HSS, Deputy Director, Divisio n of Surgery and Specialty Services M elissa Dougherty, BA(Hons) Ps ychology, Clinical Facilita to r, Redesigning Care M ichae l Szwa rcbo rd, BSc, BSocAdm in, FAIM, Executive Director, Acu te Servi ces, Southern Adelaide Health Services; and General Manager Flinders Medical Centre, Adelaide, SA. Correspondence: Professor David I Ben-Tovim , Flinders Medical Centre, Bedford Park, Adelaide, SA 5042. david.be n-tovim@fm c.sa.g ov.au
